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Showing results for "failure".

401. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836812/psn-pdf
     March 30, 2022 - Tools covered in this primer include incident reporting systems, Root Cause Analysis (RCA), and Failure … Modes and Effects Analysis Failure modes and effects analysis (FMEA) is a structured adverse event … One this is done, “failure modes”, i.e., ways in which a process or product could potentially fail or … How planning for failure can make telehealth safer. Institute for Healthcare Improvement (IHI). … [Available at] https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60234/psn-pdf
     April 15, 2020 - issue/mistakes-errors-and-failures-across-cultures-navigating-potentials Human error, mistakes and failure … While broader in its scope than health care, this book discusses failure psychology in a variety of

403. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837866/psn-pdf
     August 17, 2022 - system-need-repair-addressing-organizational-failures-uss-organ-procurement-and https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-proactive-identification-communication-and-handoff … https://psnet.ahrq.gov/issue/heart-failure-decline-historic-transplant-program https://psnet.ahrq.gov

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34936/psn-pdf
     March 12, 2009 - Another fatal failure at King/Drew. March 12, 2009 Weber T; Ornstein C. … https://psnet.ahrq.gov/issue/another-fatal-failure-kingdrew This article reports on a death that occurred … https://psnet.ahrq.gov/issue/another-fatal-failure-kingdrew

405. Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. | PSNet
     psnet.ahrq.gov/issue/failure-cap-iv-tubing-and-disinfect-iv-ports-place-patients-risk-infections
     June 10, 2018 - Newspaper/Magazine Article Failure to cap IV tubing and disinfect IV ports place … Citation Text: Failure to cap IV tubing and disinfect IV ports place patients at risk for infections … Linkedin Copy URL Cite Citation Citation Text: Failure

406. Wounded care: failure at one Indian Health Service hospital reveals a system in crisis. | PSNet
     psnet.ahrq.gov/issue/wounded-care-failure-one-indian-health-service-hospital-reveals-system-crisis
     October 05, 2016 - Newspaper/Magazine Article Wounded care: failure at one Indian Health Service hospital … Citation Text: Wounded care: failure at one Indian Health Service hospital reveals a system in crisis … Copy URL Cite Citation Citation Text: Wounded care: failure

407. Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain. | PSNet
     psnet.ahrq.gov/issue/organisational-failure-exploratory-study-steel-industry-and-medical-domain
     June 02, 2010 - Book/Report Organisational Failure: An Exploratory Study in the Steel Industry and … Citation Text: Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain … Copy URL Cite Citation Citation Text: Organisational Failure

408. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
     January 01, 2021 - communicating information (or as a source of communication errors) 10 “What We’ve Got Here is Failure … to Communicate” 11 “What We’ve Got Here is a Failure to Communicate” (1) • The two principal communicating … other conditions warranting urgent interventions such as surgery 13 “What We’ve Got Here is a Failure … to Communicate” “What We’ve Got Here is a Failure to Communicate” (1) “What We’ve Got Here is a Failure … to Communicate” (2) “What We’ve Got Here is a Failure to Communicate” (3) Approach to Improving Safety

409. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43262/psn-pdf
     April 06, 2015 - Delays in this process can lead to critical failure-to-rescue events, which may result in preventable … This study used ethnographic observations, a risk assessment survey, and a formal health care failure … escalation-care-surgery-systematic-risk-assessment-prevent-avoidable-harm-hospitalized https://psnet.ahrq.gov/primer/failure-rescue … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis https://psnet.ahrq.gov/primer

410. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46339/psn-pdf
     August 20, 2018 - Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure … Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure … retrospective, interrupted time-series analysis examined whether reduction in readmissions for heart failure … This study analyzed data from a national clinical registry of patients with heart failure admitted between

411. Missed TB | PSNet
     psnet.ahrq.gov/web-mm/missed-tb
     March 03, 2010 - The patient continued to deteriorate, with progressive respiratory failure, and died shortly afterward … 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.

412. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37107/psn-pdf
     May 02, 2018 - Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. … https://psnet.ahrq.gov/issue/failure-cap-iv-tubing-and-disinfect-iv-ports-place-patients-risk-infections … https://psnet.ahrq.gov/issue/failure-cap-iv-tubing-and-disinfect-iv-ports-place-patients-risk-infections

413. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40092/psn-pdf
     December 22, 2010 - of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure … of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure … This study, targeting patients with prolonged respiratory failure, involved adding a verbal telephone … value-adding-verbal-report-written-handoffs-early-readmission-following-prolonged-respiratory https://psnet.ahrq.gov/primer/teamwork-training https://psnet.ahrq.gov/issue/communication-failure-basic-components-contributing-factors-and-call-structure

414. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33955/psn-pdf
     June 23, 2015 - Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain. … ISBN 9038605897 https://psnet.ahrq.gov/issue/organisational-failure-exploratory-study-steel-industry-and-medical-domain … https://psnet.ahrq.gov/issue/organisational-failure-exploratory-study-steel-industry-and-medical-domain

415. Operational failures and interruptions in hospital nursing. | PSNet
     psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing
     November 03, 2021 - Study Operational failures and interruptions in hospital nursing. Citation Text: Tucker AL, Spear SJ. Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41(3 Pt 1):643-662. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndN…

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33970/psn-pdf
     March 07, 2005 - Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting. … https://psnet.ahrq.gov/issue/failure-safety-critical-systems-handbook-accident-and-incident-reporting … https://psnet.ahrq.gov/issue/failure-safety-critical-systems-handbook-accident-and-incident-reporting

417. Reduction in omission events after implementing a rapid response system: a mortality review in a department of gastrointestinal surgery. | PSNet
     psnet.ahrq.gov/issue/reduction-omission-events-after-implementing-rapid-response-system-mortality-review
     April 20, 2022 - April 20, 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 Rapid response teams and failure to rescue: one community's experience … See More About The Topic Hospitals Gastroenterology Hospital Medicine Nurse Care Failure

418. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39929/psn-pdf
     July 31, 2012 - The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses. … Safety Sci. 2011;49(1):1-106   https://psnet.ahrq.gov/issue/gift-failure-new-approaches-analyzing-and-learning-events-and-near-misses … https://psnet.ahrq.gov/issue/gift-failure-new-approaches-analyzing-and-learning-events-and-near-misses

419. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866205/psn-pdf
     July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing … Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing … https://psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited … manage intraoperative bleeding, 2) failure of the system to acknowledge staff raising concerns, 3) failure … Importance of teamwork, communication and culture on failure-to-rescue in the elderly.

420. Cutting-edge efforts in surgical patient safety. | PSNet
     psnet.ahrq.gov/issue/cutting-edge-efforts-surgical-patient-safety
     August 02, 2015 - August 2, 2015 Interpersonal and organizational dynamics are key drivers of failure to … June 18, 2019 Rapid response teams as a patient safety practice for failure to rescue … June 14, 2017 Importance of teamwork, communication and culture on failure-to-rescue … September 12, 2016 Failure to rescue following emergency surgery: a FRAM analysis of … October 4, 2011 The competent surgeon: individual accountability in the era of "systems" failure