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Total Results: 7,834 records

Showing results for "failure".

381. Meltdown: Why Our Systems Fail and What We Can Do About It. | PSNet
     psnet.ahrq.gov/issue/meltdown-why-our-systems-fail-and-what-we-can-do-about-it
     March 09, 2016 - Complex systems are prone to failure. … This book provides a multi-industry discussion of factors that contribute to failure. … highlight how complexity can exacerbate problems, small glitches can manifest themselves in large-scale failure

382. Improving process while changing practice: FMEA and medication administration. | PSNet
     psnet.ahrq.gov/issue/improving-process-while-changing-practice-fmea-and-medication-administration
     January 18, 2011 - This article describes one hospital's experience using failure mode and effects analysis (FMEA) to transform … October 4, 2011 Failure mode and effects analysis: a useful tool for risk identification … January 12, 2011 Failure mode and effect analysis: a technique to prevent chemotherapy

383. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35991/psn-pdf
     September 12, 2016 - Longitudinal analyses of nurse staffing and patient outcomes: more about failure to rescue. … https://psnet.ahrq.gov/issue/longitudinal-analyses-nurse-staffing-and-patient-outcomes-more-about-failure … https://psnet.ahrq.gov/issue/longitudinal-analyses-nurse-staffing-and-patient-outcomes-more-about-failure-rescue … https://psnet.ahrq.gov/issue/longitudinal-analyses-nurse-staffing-and-patient-outcomes-more-about-failure-rescue

384. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
     February 01, 2013 - Spotlight Case July 2008 Spotlight Case Delay in Treatment: Failure to Contact Patient Leads to Significant … to act on abnormal test results * * Case: Failure to Contact A 21-year-old woman presented to … * * Case: Failure to Contact (2) Per standard protocol, the positive laboratory result was sent … * * Case: Failure to Contact (3) One week later, the patient went to the radiology department … * * Case: Failure to Contact (5) This severe form of chlamydial infection likely developed due

385. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39730/psn-pdf
     December 21, 2014 - Surgical case listing accuracy: failure analysis at a high- volume academic medical center. … Surgical case listing accuracy: failure analysis at a high-volume academic medical center. … https://psnet.ahrq.gov/issue/surgical-case-listing-accuracy-failure-analysis-high-volume-academic-medical … https://psnet.ahrq.gov/issue/surgical-case-listing-accuracy-failure-analysis-high-volume-academic-medical-center … https://psnet.ahrq.gov/issue/surgical-case-listing-accuracy-failure-analysis-high-volume-academic-medical-center

386. CE/MOC Quizzes | PSNet
     psnet.ahrq.gov/cme
     February 26, 2025 - He underwent surgery but died three days later from multi-organ failure and sepsis caused by necrotic … February 26, 2025 Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency … Diagnostic tests revealed acute heart failure exacerbation with pulmonary edema, marked elevation of … diuretics and antihypertensives, her condition deteriorated, leading to intubation due to respiratory failure … July 31, 2024 Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response

387. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49823/psn-pdf
     March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure March 1, 2018 Bacak S, Thornburg L. … Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018. … , the incidence of acute liver failure in pregnancy remains unknown. … Some patients may have no symptoms prior to the onset of acute liver failure. … Acute liver failure. N Engl J Med. 2013;369:2525-2534. [go to PubMed] 5. Fontana RJ.

388. Hospital mortality: when failure is not a good measure of success. | PSNet
     psnet.ahrq.gov/issue/hospital-mortality-when-failure-not-good-measure-success
     December 22, 2010 - Commentary Hospital mortality: when failure is not a good measure of success. … Hospital mortality: when failure is not a good measure of success. … Hospital mortality: when failure is not a good measure of success.

389. Organizational Learning | PSNet
     psnet.ahrq.gov/curated-library/organizational-learning
     August 11, 2025 - Read More Classic Strategies for learning from failure … High reliability organizations consistently examine what goes wrong and remain aware that failure can … : the situational impact of failure on organisational learning. … : the situational impact of failure on organisational learning. … Several factors susceptible to the impact of learning from failure (e.g., workload, communication) can

390. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848125/psn-pdf
     April 26, 2023 - Failure to rescue is a serious patient safety issue in the inpatient setting; research estimates between … at three critical points: (1) failure to recognize the complications; (2) failure to relay information … to the care team, and (3) failure to react in a timely and appropriate manner. … Although it is only one part of a larger approach to addressing failure to rescue, this strategy has … Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue.

391. The future of safety and quality in radiation oncology. | PSNet
     psnet.ahrq.gov/issue/future-safety-and-quality-radiation-oncology
     May 17, 2023 - Improving Diagnostic Safety and Quality April 26, 2023 Using Failure … August 31, 2022 Using failure mode and effects analysis to increase patient safety in … February 10, 2015 Failure mode and effect analysis: a technique to prevent chemotherapy … The Topic Ambulatory Clinic or Office Medical Oncology Error Reporting and Analysis Failure

392. Clinical progress note: situation awareness for clinical deterioration in hospitalized children. | PSNet
     psnet.ahrq.gov/issue/clinical-progress-note-situation-awareness-clinical-deterioration-hospitalized-children
     January 19, 2022 - More Related Resources Patient Safety Primers Failure … April 20, 2022 Rapid response teams as a patient safety practice for failure to rescue … July 7, 2021 Failure to rescue deteriorating patients: a systematic review of root causes … Hospitals Quality and Safety Professionals Pediatrics Psychological and Social Complications Failure

393. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33568/psn-pdf
     June 15, 2024 - https://psnet.ahrq.gov/primer/systems-approach https://psnet.ahrq.gov/glossary/active-error-or-active-failure … error-prone scheduling system that identified patients by name rather than https://psnet.ahrq.gov/web-mm/failure-report … overreliance on weak solutions (such as educational interventions and enforcing existing policies), failure … to aggregate data across institutions, and failure to incorporate principles of human factors engineering … swiss-cheese-model https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety

394. Potentially inappropriate prescribing for elderly patients in 2 outpatient settings. | PSNet
     psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-elderly-patients-2-outpatient-settings
     November 18, 2009 - September 18, 2024 View More Related Resources Using Healthcare Failure … Improving Diagnostic Safety and Quality April 26, 2023 Using failure … September 13, 2017 Using Failure Mode and Effects Analysis for safe administration of … May 4, 2016 Health care failure mode and effect analysis to reduce NICU line–associated … Providers Medicine Ordering/Prescribing Errors Epidemiology of Errors and Adverse Events Failure

395. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40365/psn-pdf
     February 12, 2014 - Strategies for learning from failure. February 12, 2014 Edmondson A. … Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137. … https://psnet.ahrq.gov/issue/strategies-learning-failure Failures are inevitable in any industry, especially … https://psnet.ahrq.gov/issue/strategies-learning-failure https://psnet.ahrq.gov//#highreliabilityorganizations

396. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49442/psn-pdf
     May 01, 2004 - year-old white female with no past medical history presented to the hospital with fevers, respiratory failure … The Commentary This case represents an unfortunate failure to identify tuberculosis (TB) in a young … TB is a relatively infrequent cause of respiratory failure. … Tuberculosis as a primary cause of respiratory failure requiring mechanical ventilation. … Pulmonary tuberculosis presenting as acute respiratory failure: radiologic findings.

397. Temporal clustering of critical illness events on medical wards. | PSNet
     psnet.ahrq.gov/issue/temporal-clustering-critical-illness-events-medical-wards
     January 31, 2024 - August 31, 2022 Failure to rescue deteriorating patients: a systematic review of root … July 15, 2020 Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue … September 12, 2016 Exploratory analyses of the "failure to rescue" measure: evaluation … More About The Topic Hospitals Hospital Medicine Nurse Care Medical Complications Failure

398. Communication failure: basic components, contributing factors, and the call for structure. | PSNet
     psnet.ahrq.gov/issue/communication-failure-basic-components-contributing-factors-and-call-structure
     March 04, 2011 - Commentary Communication failure: basic components, contributing factors, and the … Communication failure: basic components, contributing factors, and the call for structure. … Communication failure: basic components, contributing factors, and the call for structure.

399. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications | PSNet
     psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
     February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications … Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. … Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. … Describe some steps that might reduce the harm from failure to act on abnormal test results. … Delay in Treatment: Failure to Contact Patient Leads to Significant Complications.

400. Empowerment failure: how shortcomings in physician communication unwittingly undermine patient autonomy. | PSNet
     psnet.ahrq.gov/issue/empowerment-failure-how-shortcomings-physician-communication-unwittingly-undermine-patient
     January 17, 2019 - Study Empowerment failure: how shortcomings in physician communication unwittingly … Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy … Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy