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Showing results for "failure".

261. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41592/psn-pdf
     August 15, 2012 - Failure mode and effects analysis outputs: are they valid? … Failure mode and effects analysis outputs: are they valid? … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-outputs-are-they-valid This study casts … doubt on the validity and reliability of failure mode and effect analysis, a commonly used tool to … /issue/healthcare-failure-mode-and-effect-analysis

262. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38655/psn-pdf
     November 25, 2009 - Is failure mode and effect analysis reliable? November 25, 2009 Shebl NA, Franklin BD, Barber N. … Is failure mode and effect analysis reliable? … https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable Failure mode and effect analysis … https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

263. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37962/psn-pdf
     September 12, 2016 - Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review. … Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review. … https://psnet.ahrq.gov/issue/exploratory-analyses-failure-rescue-measure-evaluation-through-medical- … record-review The limitations of the failure to rescue measurement at identifying systemic problems … https://psnet.ahrq.gov/issue/exploratory-analyses-failure-rescue-measure-evaluation-through-medical-record-review

264. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40865/psn-pdf
     September 12, 2016 - A review of current and emerging approaches to address failure-to-rescue. … A review of current and emerging approaches to address failure-to- rescue. … https://psnet.ahrq.gov/issue/review-current-and-emerging-approaches-address-failure-rescue Describing … failure to rescue as a key area for improvement in patient safety, this piece reviews efforts to reduce … https://psnet.ahrq.gov/issue/review-current-and-emerging-approaches-address-failure-rescue https://psnet.ahrq.gov

265. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39865/psn-pdf
     May 28, 2014 - Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third … - edition This publication provides strategies for organizations to utilize the Failure Mode and Effects … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition

266. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40004/psn-pdf
     February 01, 2011 - Application of failure mode and effect analysis in a radiology department. … Application of Failure Mode and Effect Analysis in a Radiology Department. … https://psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department This … commentary introduces the failure mode and effects analysis process developed by the United States Department … https://psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department https:

267. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35322/psn-pdf
     July 14, 2009 - Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber … Safe chemotherapy administration: Using failure mode and effects analysis in computerized prescriber … https://psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis … - computerized This case study describes one hospital’s use of failure mode and effects analysis (FMEA … https://psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis-computerized

268. Failure to weigh patients in hospital: a medication safety risk. | PSNet
     psnet.ahrq.gov/issue/failure-weigh-patients-hospital-medication-safety-risk
     April 22, 2015 - Study Failure to weigh patients in hospital: a medication safety risk. … Failure to weigh patients in hospital: a medication safety risk. Intern Med J. 2007;37(9):647-50. … Failure to weigh patients in hospital: a medication safety risk.

269. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38753/psn-pdf
     July 01, 2009 - Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … https://psnet.ahrq.gov/issue/evaluation-safety-radiation-oncology-setting-using-failure-mode-and-effects … - analysis Failure mode and effects analysis was used to prospectively analyze an external beam radiation … https://psnet.ahrq.gov/issue/evaluation-safety-radiation-oncology-setting-using-failure-mode-and-effects-analysis

270. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38867/psn-pdf
     March 01, 2011 - Management of anesthesia equipment failure: a simulation-based resident skill assessment. … Management of Anesthesia Equipment Failure: A Simulation- Based Resident Skill Assessment. … https://psnet.ahrq.gov/issue/management-anesthesia-equipment-failure-simulation-based-resident-skill- … assessment Anesthesia residents' ability to handle intraoperative equipment failure was evaluated … https://psnet.ahrq.gov/issue/management-anesthesia-equipment-failure-simulation-based-resident-skill-assessment

271. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37086/psn-pdf
     October 03, 2011 - Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury … discusses the importance of proactive risk assessment and provides insights on the successful use of failure … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury-prevention

272. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42995/psn-pdf
     September 12, 2016 - Failure events in transition of care for surgical patients. … Failure events in transition of care for surgical patients. … https://psnet.ahrq.gov/issue/failure-events-transition-care-surgical-patients Wide variation in hospital … factors associated with unplanned transfers to the intensive care unit after surgery and found that failure … https://psnet.ahrq.gov/issue/failure-events-transition-care-surgical-patients https://psnet.ahrq.gov/

273. Despite Clues, Failed to Rescue | PSNet
     psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
     August 02, 2015 - Case Objectives Define failure to rescue. … Identify the main contributors to failure-to-rescue events. … Failure-to-rescue is the failure to prevent a clinically important deterioration, such as death or permanent … Take-Home Points Failure to rescue is a failure to prevent a clinically important deterioration, … Conceptual Model for Understanding and Improving Failure to Rescue.

274. First, Do No Harm Part 1: A Case Study of Systems Failure. | PSNet
     psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure
     September 07, 2022 - Audiovisual Presentation First, Do No Harm Part 1: A Case Study of Systems Failure … Citation Text: First, Do No Harm Part 1: A Case Study of Systems Failure. … Cite Citation Citation Text: First, Do No Harm Part 1: A Case Study of Systems Failure

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36207/psn-pdf
     October 13, 2010 - Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. … Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-plan-implementation-smart-iv-pump … - technology The authors describe their use of failure mode and effects analysis to inform the launch … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-plan-implementation-smart-iv-pump-technology

276. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41006/psn-pdf
     December 21, 2011 - Failure to notify reportable test results: significance in medical malpractice. … Failure to notify reportable test results: significance in medical malpractice. … https://psnet.ahrq.gov/issue/failure-notify-reportable-test-results-significance-medical-malpractice … malpractice claims over an 18-year period identified more than 300 cases of malpractice attributable to failure … https://psnet.ahrq.gov/issue/failure-notify-reportable-test-results-significance-medical-malpractice

277. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41022/psn-pdf
     December 21, 2011 - Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects … https://psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis- failure-mode-and … This commentary recommends that courses covering root cause analysis, failure mode and effects analysis … https://psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and

278. The Forgotten Drip | PSNet
     psnet.ahrq.gov/web-mm/forgotten-drip
     April 01, 2014 - Nephrology was consulted to help determine the etiology of the hypernatremia and renal failure and to … He had a prolonged hospitalization and ultimately died from complications related to renal failure. … Dosing should be limited to less than 250 mg/kg every 4 hours to reduce the chances of renal failure. … ( 7 ) In patients with preexisting oliguric or anuric renal failure, including patients on dialysis, … Mannitol-induced acute renal failure. Medicine (Baltimore). 1990;69:153-159. [go to PubMed] 8.

279. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867696/psn-pdf
     March 05, 2025 - Topics include the importance of understanding failure to rescue, the patient’s role in care escalation … textbook-rapid-response-systems-concept-and-implementation https://psnet.ahrq.gov/issue/rapid-response-systems-0 https://psnet.ahrq.gov/primer/failure-rescue … https://psnet.ahrq.gov/primer/failure-rescue https://psnet.ahrq.gov/issue/understanding-enablers-and-barriers-implementing-patient-led-escalation-system-qualitative

280. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39735/psn-pdf
     January 03, 2017 - A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and … A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and … https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most … - team-and-its This commentary describes one hospital's experience implementing Failure Mode and Effects … https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its