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Total Results: 7,834 records

Showing results for "failure".

341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853902/psn-pdf
     September 27, 2023 - , failure to identify and target early sepsis, and then failure to pursue source control with surgical … volume overload, presumably heart failure, and this initial diagnosis likely had a powerful impact … on the failure to consider alternative diagnoses. … There was failure in the fourth step in the diagnostic process, verifying the diagnosis by ruling out … competing alternative hypotheses, due to failure to perform a bedside exam when multiple red flags

342. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36413/psn-pdf
     July 13, 2010 - Implications of the failure to identify high-risk electrocardiogram findings for the quality of care … Implications of the failure to identify high-risk electrocardiogram findings for the quality of care … https://psnet.ahrq.gov/issue/implications-failure-identify-high-risk-electrocardiogram-findings-quality-care … https://psnet.ahrq.gov/issue/implications-failure-identify-high-risk-electrocardiogram-findings-quality-care-patients … https://psnet.ahrq.gov/issue/implications-failure-identify-high-risk-electrocardiogram-findings-quality-care-patients

343. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38797/psn-pdf
     July 22, 2009 - Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic … Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic … https://psnet.ahrq.gov/issue/failure-recognize-newly-identified-aortic-dilations-health-care-system- … https://psnet.ahrq.gov/issue/failure-recognize-newly-identified-aortic-dilations-health-care-system-advanced-electronic … https://psnet.ahrq.gov/issue/failure-recognize-newly-identified-aortic-dilations-health-care-system-advanced-electronic

344. Mock trial at 2009 RSNA annual meeting: jury exonerates radiologist for failure to communicate abnormal finding—but... | PSNet
     psnet.ahrq.gov/issue/mock-trial-2009-rsna-annual-meeting-jury-exonerates-radiologist-failure-communicate-abnormal
     October 23, 2018 - Commentary Mock trial at 2009 RSNA annual meeting: jury exonerates radiologist for failure … 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 … March 4, 2015 Failure to notify reportable test results: significance in medical malpractice

345. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47751/psn-pdf
     May 01, 2019 - Heart Failure: The Decline of a Historic Transplant Program. … https://psnet.ahrq.gov/issue/heart-failure-decline-historic-transplant-program This news investigation … https://psnet.ahrq.gov/issue/heart-failure-decline-historic-transplant-program https://psnet.ahrq.gov

346. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43681/psn-pdf
     June 03, 2016 - Learning from failure: the need for independent safety investigation in healthcare. … Learning from failure: the need for independent safety investigation in healthcare. … https://psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare High … https://psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare https: … //psnet.ahrq.gov/issue/strategies-learning-failure https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical

347. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39975/psn-pdf
     March 03, 2011 - Communication failure in the operating room. … Communication failure in the operating room. … https://psnet.ahrq.gov/issue/communication-failure-operating-room Communication failures are a well-characterized … to assess the incidence, types, and consequences of surgical communication problems, and found that failure … https://psnet.ahrq.gov/issue/communication-failure-operating-room https://psnet.ahrq.gov/issue/operating-room-teamwork-among-physicians-and-nurses-teamwork-eye-beholder

348. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47304/psn-pdf
     October 24, 2018 - Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. … Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. … https://psnet.ahrq.gov/issue/mind-overlap-how-system-problems-contribute-cognitive-failure-and- diagnostic-errors … https://psnet.ahrq.gov/issue/mind-overlap-how-system-problems-contribute-cognitive-failure-and-diagnostic-errors … https://psnet.ahrq.gov/issue/mind-overlap-how-system-problems-contribute-cognitive-failure-and-diagnostic-errors

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47287/psn-pdf
     December 19, 2018 - Shifting and sharing: academic physicians' strategies for navigating underperformance and failure. … Shifting and Sharing: Academic Physicians' Strategies for Navigating Underperformance and Failure. … psnet.ahrq.gov/issue/shifting-and-sharing-academic-physicians-strategies-navigating- underperformance-and-failure … psnet.ahrq.gov/issue/shifting-and-sharing-academic-physicians-strategies-navigating-underperformance-and-failure … psnet.ahrq.gov/issue/shifting-and-sharing-academic-physicians-strategies-navigating-underperformance-and-failure

350. Ways to avert potential patient care disasters. | PSNet
     psnet.ahrq.gov/issue/ways-avert-potential-patient-care-disasters
     March 01, 2007 - This article discusses clinician failure to recognize patient deterioration and provides recommendations … Related Resources From the Same Author(s) WebM&M Cases Failure … Analysis July 1, 2008 Letter In response to "Failure

351. Resilience Engineering: Concepts and Precepts. | PSNet
     psnet.ahrq.gov/issue/resilience-engineering-concepts-and-precepts
     January 12, 2011 - must anticipate risk and continuously adapt to the complexity of their work environments to prevent failure … October 14, 2020 Managing clinical failure: a complex adaptive system perspective. … September 1, 2011 Risk, society and system failure.

352. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34083/psn-pdf
     June 30, 2011 - Handoff strategies in settings with high consequences for failure: lessons for health care operations … Handoff strategies in settings with high consequences for failure: lessons for health care operations … https://psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care … https://psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations … https://psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations

353. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. | PSNet
     psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations-bristol-royal
     April 08, 2011 - Commentary A very public failure: lessons for quality improvement in healthcare organisations … A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal … A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal … Related Resources From the Same Author(s) Understanding and learning from organisational failure

354. The role of documents and documentation in communication failure across the perioperative pathway. A literature review. | PSNet
     psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across-perioperative-pathway
     November 06, 2015 - Review The role of documents and documentation in communication failure across the … 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. … August 25, 2011 Communication failure in the operating room.

355. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848365/psn-pdf
     May 03, 2023 - issue/value-improving-patient-safety-health-economic-considerations-rapid- response-systems-rapid Failure … the authors used health economics methods to understand the health economic impacts associated with failure … value-improving-patient-safety-health-economic-considerations-rapid-response-systems-rapid https://psnet.ahrq.gov/primer/failure-rescue

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72677/psn-pdf
     January 27, 2021 - psnet.ahrq.gov/issue/implementation-science-approach-promote-optimal-implementation-adoption- use-and-spread Failure … efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue … implementation-science-approach-promote-optimal-implementation-adoption-use-and-spread https://psnet.ahrq.gov/primer/failure-rescue

357. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33579/psn-pdf
     September 15, 2024 - as root cause analysis (or the more generic term systems analysis) and prospective methods such as failure … Failure modes effect analysis (FMEA) attempts to prospectively identify error-prone situations, or failure … The estimates of the likelihood of a particular process failure, the chance of detecting such failure … Each step in this process would be assigned a probability of failure and an impact score, so that all … https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable https://psnet.ahrq.gov/issue/

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49867/psn-pdf
     July 02, 2019 - morbid obesity and a past medical history of chronic obstructive pulmonary disease, hypertension, heart failure … with loop diuretics is usually due to the conditions they are commonly used to treat, namely heart failure … and ascites.(5) Thiazides can help reduce water retention in patients with mild congestive heart failure … 62-year-old woman.(6) However, the patient did not report any other new symptoms suggesting heart failure … the course of weeks, whereas symptoms generally appear more suddenly when edema is caused by heart failure

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36219/psn-pdf
     October 18, 2010 - Risk, society and system failure. October 18, 2010 Scalliet P. Risk, society and system failure. … https://psnet.ahrq.gov/issue/risk-society-and-system-failure The author discusses why large scale accidents … https://psnet.ahrq.gov/issue/risk-society-and-system-failure

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45710/psn-pdf
     December 22, 2017 - Our current approach to root cause analysis: is it contributing to our failure to improve patient safety … Our current approach to root cause analysis: is it contributing to our failure to improve patient safety … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety