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Total Results: 7,834 records

Showing results for "failure".

361. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43363/psn-pdf
     September 12, 2016 - Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. … Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. … https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative … https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study … https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33959/psn-pdf
     January 17, 2012 - Healthcare Failure Mode and Effect Analysis. … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis These materials provide an … introduction to the purpose of healthcare failure mode and effect analysis (HFMEA), the steps of the … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis

363. Spotlight Case September 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
     September 01, 2003 - of message transmission Failure of message reception Failure of message acknowledgment Failure … of Message Transmission Failure to inform ICU doctor fails to inform anesthesiologist doing nasal … to act on message Distraction leads to delay or failure to give requested drug Failure of Message … that heparin be administered Failure to acknowledge understanding Team member responds with “uh-huh … ” rather than explicit read-back of instructions given Failure to state when action taken Requested

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846759/psn-pdf
     March 29, 2023 - The primary contributing factors to wrong-site surgery was failure to follow policy or protocols (such … as failure to follow the Universal Protocol) and failure to review medical records.

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36124/psn-pdf
     June 15, 2011 - System failure versus personal accountability--the case for clean hands. … System failure versus personal accountability--the case for clean hands. … https://psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands The author … https://psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands https://psnet.ahrq.gov

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46624/psn-pdf
     November 29, 2017 - Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy … Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy … https://psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly … https://psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient … https://psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38879/psn-pdf
     March 02, 2011 - The competent surgeon: individual accountability in the era of "systems" failure. … The competent surgeon: individual accountability in the era of "systems" failure. … https://psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure Discussing … https://psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36911/psn-pdf
     September 01, 2011 - Managing clinical failure: a complex adaptive system perspective. … Managing clinical failure: a complex adaptive system perspective. … https://psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective The investigators … https://psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39542/psn-pdf
     May 19, 2010 - Random safety auditing, root cause analysis, failure mode and effects analysis. … Random Safety Auditing, Root Cause Analysis, Failure Mode and Effects Analysis. … https://psnet.ahrq.gov/issue/random-safety-auditing-root-cause-analysis-failure-mode-and-effects-analysis … https://psnet.ahrq.gov/issue/random-safety-auditing-root-cause-analysis-failure-mode-and-effects-analysis

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/844535/psn-pdf
     February 15, 2023 - unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure … unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure … In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836724/psn-pdf
     March 09, 2022 - issue/when-no-news-bad-news-improving-diagnostic-testing-communication- through-patient-engagement Failure … when-no-news-bad-news-improving-diagnostic-testing-communication-through-patient-engagement https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications … https://psnet.ahrq.gov/issue/failure-notify-reportable-test-results-significance-medical-malpractice

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37177/psn-pdf
     October 06, 2011 - 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. … https://psnet.ahrq.gov/issue/failure-weigh-patients-hospital-medication-safety-risk Patients in this … https://psnet.ahrq.gov/issue/failure-weigh-patients-hospital-medication-safety-risk https://psnet.ahrq.gov

373. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41047/psn-pdf
     November 26, 2014 - Failure to follow-up test results for ambulatory patients: a systematic review. … Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review. … https://psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review Following … This systematic review found evidence that failure to act on abnormal radiology or laboratory results … https://psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review https:

374. AHRQ PSNet Webinar (pdf file)
     psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
     January 01, 2025 - to Rescue – Rapid Response Systems Rapid Review Failure to Rescue – Rapid Response Systems: … of cardiorespiratory arrest post arrival in PICU Significant decrease Children Afferent Limb Failure … to rescue likely resides with the afferent limb failure problem, attempts have been made to address … to Rescue – Rapid Response Systems Rapid Review Slide 19: Failure to Rescue – Rapid Response Systems … to Rescue in General Hospital Wards Slide 31: Rapid Response Systems that Aim to Mitigate Failure to

375. Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. | PSNet
     psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study
     September 09, 2015 - Study Classic Escalation of care and failure to rescue: … Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. … Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. … September 9, 2015 A systematic review to identify the factors that affect failure to

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37956/psn-pdf
     July 30, 2008 - Hospital mortality: when failure is not a good measure of success. … Hospital mortality: when failure is not a good measure of success. … https://psnet.ahrq.gov/issue/hospital-mortality-when-failure-not-good-measure-success This commentary … https://psnet.ahrq.gov/issue/hospital-mortality-when-failure-not-good-measure-success https://psnet.ahrq.gov

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42291/psn-pdf
     September 12, 2016 - Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. … Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. … https://psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case This commentary … https://psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case https://

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41519/psn-pdf
     September 01, 2016 - Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically … Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically … https://psnet.ahrq.gov/issue/failure-utilize-functions-electronic-prescribing-system-and-subsequent- … https://psnet.ahrq.gov/issue/failure-utilize-functions-electronic-prescribing-system-and-subsequent-generation-technically … https://psnet.ahrq.gov/issue/failure-utilize-functions-electronic-prescribing-system-and-subsequent-generation-technically

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42177/psn-pdf
     November 23, 2016 - Failure to engage hospitalized elderly patients and their families in advance care planning. … Failure to engage hospitalized elderly patients and their families in advance care planning. … https://psnet.ahrq.gov/issue/failure-engage-hospitalized-elderly-patients-and-their-families-advance-care … https://psnet.ahrq.gov/issue/failure-engage-hospitalized-elderly-patients-and-their-families-advance-care-planning … https://psnet.ahrq.gov/issue/failure-engage-hospitalized-elderly-patients-and-their-families-advance-care-planning

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50773/psn-pdf
     January 08, 2020 - psnet.ahrq.gov/issue/effect-cognitive-aids-adherence-best-practice-treatment-deteriorating-surgical- patients Failure … Use of cognitive aids significantly reduced omitted critical management steps and failure to adhere … effect-cognitive-aids-adherence-best-practice-treatment-deteriorating-surgical-patients https://psnet.ahrq.gov/primer/failure-rescue