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Showing results for "failure".

421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49514/psn-pdf
     July 01, 2006 - A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure … The patient had two apparent indications for an ACE inhibitor: type 2 diabetes and congestive heart failure … predispose to hyperkalemia—diabetes because of hyporeninemic hypoaldosteronism and congestive heart failure … In the Randomized Aldactone Evaluation Study (RALES), only 1.7% of heart failure patients treated with … The effect of spironolactone on morbidity and mortality in patients with severe heart failure.

422. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44783/psn-pdf
     January 13, 2016 - black-box-thinking-why-most-people-never-learn-their-mistakes-some-do Medicine and aviation are high-risk industries where failure … black-box-thinking-why-most-people-never-learn-their-mistakes-some-do https://psnet.ahrq.gov/issue/error-management-lessons-aviation https://psnet.ahrq.gov/issue/failure-and-rescue … https://psnet.ahrq.gov/issue/strategies-learning-failure

423. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45194/psn-pdf
     December 14, 2016 - Wounded care: failure at one Indian Health Service hospital reveals a system in crisis. … https://psnet.ahrq.gov/issue/wounded-care-failure-one-indian-health-service-hospital-reveals-system-crisis … https://psnet.ahrq.gov/issue/wounded-care-failure-one-indian-health-service-hospital-reveals-system-crisis

424. One ACE Too Many | PSNet
     psnet.ahrq.gov/web-mm/one-ace-too-many
     June 21, 2016 - A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure … The patient had two apparent indications for an ACE inhibitor: type 2 diabetes and congestive heart failure … predispose to hyperkalemia—diabetes because of hyporeninemic hypoaldosteronism and congestive heart failure … In the Randomized Aldactone Evaluation Study (RALES), only 1.7% of heart failure patients treated with … The effect of spironolactone on morbidity and mortality in patients with severe heart failure.

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74259/psn-pdf
     January 19, 2022 - https://psnet.ahrq.gov/issue/diagnostic-reasoning-cardiovascular-medicine Misdiagnosis of heart failure … /issue/diagnostic-reasoning-cardiovascular-medicine https://psnet.ahrq.gov/issue/misdiagnosis-heart-failure-systematic-review-literature

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34728/psn-pdf
     December 19, 2016 - Forgive and Remember: Managing Medical Failure. 2nd ed. … https://psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed In this seminal study … https://psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed

427. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44190/psn-pdf
     June 03, 2015 - health care safety efforts after her daughter died due to a series of medical mistakes, including failure … pulse-center-patient-safety-education-advocacy https://psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case … https://psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33653/psn-pdf
     June 01, 2007 - In response to "Failure to Report" (March 2007) June 1, 2007 Paparella S, Vaida AJ, Spath P. … In response to "Failure to Report" (March 2007). PSNet [internet]. 2007. … https://psnet.ahrq.gov/perspective/response-failure-report-march-2007 In response to "Failure to Report … the vials that accompanied the commentary, we felt that https://psnet.ahrq.gov/perspective/response-failure-report-march … -2007 https://psnet.ahrq.gov/web-mm/failure-report the manufacturers had done a fairly good job of

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34737/psn-pdf
     November 19, 2015 - First, Do No Harm Part 1: A Case Study of Systems Failure. … https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure This video, produced … https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure https://psnet.ahrq.gov

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50578/psn-pdf
     October 23, 2019 - people-work-safely The systems approach embodies a holistic strategy to correct conditions that contribute to failure … This book discusses learning from failure and from what works as components to engaging workers in

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46773/psn-pdf
     January 24, 2018 - /issue/patient-safety-complementary-medicine-through-application-clinical-risk- management-public Failure … This study describes the application of failure mode and effect analysis to better understand the patient … patient-safety-complementary-medicine-through-application-clinical-risk-management-public https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50837/psn-pdf
     January 29, 2020 - This brief summarizes gaps in failure to rescue processes and shares recommendations for health systems … hospital-readmission-after-noncardiac-surgery-role-major-complications https://psnet.ahrq.gov/primer/failure-rescue

433. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837346/psn-pdf
     June 08, 2022 - psnet.ahrq.gov/issue/decontamination-surgical-instruments https://psnet.ahrq.gov/issue/applicability-healthcare-failure-mode-and-effects-analysis-healthcare-epidemiology-evaluation … https://psnet.ahrq.gov/issue/applicability-healthcare-failure-mode-and-effects-analysis-healthcare-epidemiology-evaluation

434. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/842920
     December 14, 2022 - , a mixture of shortcomings in clinicians’ understanding of the disease, diagnostic biases, and the failure … Renal Failure Due to Benign Prostatic Hyperplasia Michael J. Barry, MD, and Marc B. … , a mixture of shortcomings in clinicians’ understanding of the disease, diagnostic biases, and the failure … Renal Failure Due to Benign Prostatic Hyperplasia Michael J. Barry, MD, and Marc B. … psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis https://psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia

435. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848829/psn-pdf
     May 10, 2023 - https://psnet.ahrq.gov/issue/lessons-covid-war-investigative-report The transfer of failure experiences … lessons-covid-war-investigative-report https://psnet.ahrq.gov/issue/how-pandemic-defeated-america https://psnet.ahrq.gov/issue/failure-crisis-leadership-global-pandemic-some-reflections-covid

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48054/psn-pdf
     June 26, 2019 - effective signage, appropriate security staff placement, and acceptance of the responsibility for failure … issue/lessons-learned-death-outside-hospitals-doorstep https://psnet.ahrq.gov/issue/strategies-learning-failure

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45599/psn-pdf
     July 02, 2017 - combined the narratives of various critical care nurses into four representative scenarios demonstrating failure … environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue … invisible-gorilla-and-other-ways-our-intuitions-deceive-us https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47756/psn-pdf
     February 06, 2019 - psnet.ahrq.gov/issue/meltdown-why-our-systems-fail-and-what-we-can-do-about-it 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

439. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
     March 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case March 2007 Failure to Report Source and Credits This … Case: Failure to Report Several hours later, when removing another vial of ceftriaxone from the automated … of safe guards RN failure to confirm med identity prior to administration An environment predisposed … Case: Failure to Report (cont.) … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10720336 Failure to Acknowledge Errors Even when

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47852/psn-pdf
     May 08, 2019 - factors-underlying-suboptimal-diagnostic-performance-physicians-under-time-pressure https://psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review … https://psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review