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Showing results for "failure".

321. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38469/psn-pdf
     March 11, 2009 - Post-discharge medication reviews for patients with heart failure: a pilot study. … Post-discharge medication reviews for patients with heart failure: a pilot study. … https://psnet.ahrq.gov/issue/post-discharge-medication-reviews-patients-heart-failure-pilot-study A … successfully implemented in order to improve postdischarge care for patients with congestive heart failure … https://psnet.ahrq.gov/issue/post-discharge-medication-reviews-patients-heart-failure-pilot-study https

322. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34601/psn-pdf
     January 26, 2009 - Strategies and tips for maximizing failure mode and effect analysis in your organization. … https://psnet.ahrq.gov/issue/strategies-and-tips-maximizing-failure-mode-and-effect-analysis-your- organization … Risk managers provide pearls from their experience, applying failure mode and effects analysis (FMEA … https://psnet.ahrq.gov/issue/strategies-and-tips-maximizing-failure-mode-and-effect-analysis-your-organization … https://psnet.ahrq.gov/issue/strategies-and-tips-maximizing-failure-mode-and-effect-analysis-your-organization

323. Sensemaking of patient safety risks and hazards. | PSNet
     psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
     March 03, 2011 - sensemaking before discussing both retrospective (eg, root cause analysis ) and prospective (eg, failure … 1, 2017 Key performance outcomes of patient safety curricula: root cause analysis, failure … July 29, 2010 Random safety auditing, root cause analysis, failure mode and effects analysis … More About The Topic Risk Managers Organizational Behaviorists Root Cause Analysis Failure

324. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41663/psn-pdf
     January 31, 2013 - Physician patient communication failure facilitates medication errors in older polymedicated patients … Physician patient communication failure facilitates medication errors in older polymedicated patients … https://psnet.ahrq.gov/issue/physician-patient-communication-failure-facilitates-medication-errors-older … https://psnet.ahrq.gov/issue/physician-patient-communication-failure-facilitates-medication-errors-older-polymedicated … https://psnet.ahrq.gov/issue/physician-patient-communication-failure-facilitates-medication-errors-older-polymedicated

325. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41588/psn-pdf
     August 15, 2012 - Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with … Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with … https://psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation- failure-patients-trauma … https://psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-failure-patients-trauma … https://psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-failure-patients-trauma

326. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867606/psn-pdf
     February 10, 2025 - Failure To Rescue – Rapid Response Systems reviews rapid response systems’ impacts on patient safety … making-healthcare-safer-iv-continuous-updating-patient-safety-harms-and-practices https://effectivehealthcare.ahrq.gov/products/mhs4-failure-rescue … /rapid-research https://effectivehealthcare.ahrq.gov/products/mhs4-failure-rescue/rapid-research https

327. Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network. | PSNet
     psnet.ahrq.gov/issue/testing-process-errors-and-their-harms-and-consequences-reported-family-medicine-practices
     June 11, 2008 - Failure to follow up on test results has been linked to missed and delayed diagnoses and significant … Ranging from incorrect test ordering to failure to provide test results to clinicians and patients, these … errors frequently resulted in failure to provide timely patient care.  … February 18, 2011 Frequency of failure to inform patients of clinically significant outpatient

328. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39873/psn-pdf
     January 22, 2017 - A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician … A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician … https://psnet.ahrq.gov/issue/proactive-risk-avoidance-system-using-failure-mode-and-effects-analysis- … raised by a physician with a common last name during executive walk rounds, the institution conducted a failure … https://psnet.ahrq.gov/issue/proactive-risk-avoidance-system-using-failure-mode-and-effects-analysis-same-name-physician

329. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38889/psn-pdf
     April 01, 2010 - Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation … Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation … https://psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry … https://psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry-system … https://psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry-system

330. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34991/psn-pdf
     June 22, 2009 - Use of failure mode and effects analysis in improving the safety of i.v. drug administration. … Use of failure mode and effects analysis in improving the safety of i.v. drug administration. … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration … The authors used failure mode and effects analysis (FMEA) to identify dosing and administration errors … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration

331. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49544/psn-pdf
     September 01, 2007 - Heart Failure Society of America. HFSA 2006 comprehensive heart failure practice guideline. … Clinical Performance Measures) endorsed by the Heart Failure Society of America. … Discharge education improves clinical outcomes in patients with chronic heart failure. … With The Guidelines (GWTG) heart failure program. … Joint Commission/CMS Heart Failure Inpatient Performance Measure Descriptions.

332. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50722/psn-pdf
     December 04, 2019 - 20 years later: to err is a leadership failure. December 4, 2019 Castellucci M, Meyer H. … https://psnet.ahrq.gov/issue/20-years-later-err-leadership-failure This special segment shares commentaries … https://psnet.ahrq.gov/issue/20-years-later-err-leadership-failure https://psnet.ahrq.gov/issue/err-human-building-safer-health-system

333. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36838/psn-pdf
     April 19, 2011 - A very public failure: lessons for quality improvement in healthcare organisations from the Bristol … A very public failure: lessons for quality improvement in healthcare organisations from the Bristol … https://psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations … https://psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations-bristol-royal … https://psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations-bristol-royal

334. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44910/psn-pdf
     March 09, 2016 - Systematically Identified Failure Is the Route to a Successful Health System. … https://psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system Identifying … Exploring challenges to system-level efforts to learn from failure in health care, articles in this … https://psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system https:/ … learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and https://psnet.ahrq.gov/issue/strategies-learning-failure

335. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40620/psn-pdf
     July 22, 2011 - The role of documents and documentation in communication failure across the perioperative pathway. … The role of documents and documentation in communication failure across the perioperative pathway. … https://psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across- perioperative-pathway … https://psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across-perioperative-pathway … https://psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across-perioperative-pathway

336. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40195/psn-pdf
     February 02, 2011 - Mock trial at 2009 RSNA annual meeting: jury exonerates radiologist for failure to communicate abnormal … Mock trial at 2009 RSNA annual meeting: Jury exonerates radiologist for failure to communicate abnormal … https://psnet.ahrq.gov/issue/mock-trial-2009-rsna-annual-meeting-jury-exonerates-radiologist-failure- … https://psnet.ahrq.gov/issue/mock-trial-2009-rsna-annual-meeting-jury-exonerates-radiologist-failure-communicate-abnormal … https://psnet.ahrq.gov/issue/mock-trial-2009-rsna-annual-meeting-jury-exonerates-radiologist-failure-communicate-abnormal

337. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866080/psn-pdf
     June 05, 2024 - giving-learning-failures-examination-learning-ones-own-failures-context-heart- surgeons Learning from failure … giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons https://psnet.ahrq.gov/issue/strategies-learning-failure

338. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43915/psn-pdf
     September 27, 2017 - The quality of hospital work environments and missed nursing care is linked to heart failure readmissions … The quality of hospital work environments and missed nursing care is linked to heart failure readmissions … https://psnet.ahrq.gov/issue/quality-hospital-work-environments-and-missed-nursing-care-linked-heart- failure-readmissions … ' work environment and more frequent reports of missed care also had higher readmissions for heart failure … https://psnet.ahrq.gov/issue/quality-hospital-work-environments-and-missed-nursing-care-linked-heart-failure-readmissions

339. Hyponatremia Secondary to Home Parenteral Nutrition Error | PSNet
     psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
     May 27, 2020 - The Commentary By Kelly Haas, MD, and Andrew Lee, PharmD Pediatric intestinal failure occurs … Pediatric Intestinal Failure. N Engl J Med. 2017;377(7):666-675. … Long-term outcomes of pediatric intestinal failure.  … Coordinated interdisciplinary management of pediatric intestinal failure: a 2-year review. … Clinical outcomes in pediatric intestinal failure: a meta-analysis and meta-regression. 

340. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43385/psn-pdf
     August 06, 2014 - Medicines management support to older people: understanding the context of systems failure. … Medicines management support to older people: understanding the context of systems failure. … https://psnet.ahrq.gov/issue/medicines-management-support-older-people-understanding-context-systems- failure … https://psnet.ahrq.gov/issue/medicines-management-support-older-people-understanding-context-systems-failure … https://psnet.ahrq.gov/issue/medicines-management-support-older-people-understanding-context-systems-failure