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Showing results for "failure".

441. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47997/psn-pdf
     May 08, 2019 - These weaknesses involve the tension between prospective and retrospective preventability, failure to … issue/organizing-patient-safety-failsafe-fantasies-and-pragmatic-practices https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-too-little-too-much

442. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48043/psn-pdf
     October 01, 2023 - of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure … psnet.ahrq.gov/issue/health-services-safety-investigations-body https://psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare

443. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45393/psn-pdf
     November 16, 2016 - for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure … for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure … independent physician chart review to assess the reliability of PSI 11 (postoperative respiratory failure

444. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37837/psn-pdf
     June 11, 2008 - Failure to follow up on test results has been linked to missed and delayed diagnoses and significant … Ranging from incorrect test ordering to failure to provide test results to clinicians and patients, … these errors frequently resulted in failure to provide timely patient care. 

445. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42439/psn-pdf
     November 23, 2016 - This failure to provide patient-centered care indicates a need for increased patient engagement in safety … /issue/guide-patient-and-family-engagement-hospital-quality-and-safety 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

446. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39402/psn-pdf
     August 08, 2010 - article reviews the history of safety initiatives around vincristine and identifies five domains of failure … , ranging from failure to adequately investigate cases to failure to translate safety solutions internationally

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36907/psn-pdf
     September 14, 2012 - One notable addition to the original list is that serious harm associated with failure to properly follow … issue/fire-safety https://psnet.ahrq.gov/web-mm/flying-object-hits-mri 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 https

448. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49806/psn-pdf
     September 01, 2017 - The emergency physician assessed the patient as having either new onset congestive heart failure or an … Two diagnostic tests were ordered: an echocardiogram for heart failure and both blood and sputum cultures … He received diuretics for the potential diagnosis of heart failure, but he was not empirically treated … Defined as a mistake or failure in the process leading to a misdiagnosis, a missed diagnosis, or delay … exam findings evident of fluid overload or prior history of heart failure.

449. Diuretics and Electrolyte Abnormalities | PSNet
     psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
     February 15, 2017 - 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 … (loop diuretics are indicated in case of more severe symptoms), and worsening heart failure was a possible … 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

450. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49617/psn-pdf
     January 01, 2011 - Failure to Reevaluate December 1, 2010 Wong-Beringer A. Failure to Reevaluate. … https://psnet.ahrq.gov/web-mm/failure-reevaluate The Case A 61-year-old woman receiving palliative … The patient was recognized to be in acute renal failure when her creatinine reached 1.09 mg/dL the day … As a result of her renal failure, the patient rapidly developed non-anion gap metabolic acidosis and, … Urine and blood studies failed to identify a clear cause of her renal failure.

451. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49559/psn-pdf
     April 01, 2008 - Nephrology was consulted to help determine the etiology of the hypernatremia and renal failure and to … He had a prolonged hospitalization and ultimately died from complications related to renal failure. … Dosing should be limited to less than 250 mg/kg every 4 hours to reduce the chances of renal failure … .(7) In patients with preexisting oliguric or anuric renal failure, including patients on dialysis, … Mannitol-induced acute renal failure. Medicine (Baltimore). 1990;69:153-159. [go to PubMed] 8.

452. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.95_slideshow.ppt
     May 01, 2005 - Evaluation of a case with knowledge of the patient’s outcome (hindsight bias) Lack of a gold standard Failure … to consider the spectrum of clinical presentations Failure to consider the consequences of competing … Failure to Consider Hindsight Bias Patient classified as low risk for adverse outcomes (0.1%-0.4% mortality … Can the clinical examination diagnose left-sided heart failure in adults? … cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12008187 Failure to Consider Consequences of Competing

453. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
     May 01, 2010 - Identify best sources of information for designing a response to an error Distinguish accountability for failure … and learning from failure * * Case: Fatal Error in Neonate (1) An infant was born prematurely … He showed signs of respiratory distress, pulmonary hypertension, coagulopathy, and liver failure. … with accountability for failure In this case, the response seems unjust: only (one narrow form of) … care generally overestimates the role of the individual actor in bringing about clinical success or failure

454. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40167/psn-pdf
     January 22, 2017 - More than 25% of surveyed trainees witnessed a failure of supervision, which were categorized into three … Supervisors' failure to respond to trainees seeking guidance and the trainees' failure themselves to

455. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41257/psn-pdf
     April 22, 2012 - many researchers have tried to provide additional frameworks that help define the root causes and key failure … framework-patient-safety-research-and-improvement https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys … https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

456. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33815/psn-pdf
     September 01, 2016 - telemonitoring reduced all-cause mortality by 15%-40% and heart failure-related hospitalizations by … Another systematic review found that, compared with usual care, telemonitoring for patients with heart failure … For instance, the heart failure telemonitoring program (Connected Cardiac Care Program) at Partners … Effects of home telemonitoring interventions on patients with chronic heart failure: an overview of … Cost comparison between telemonitoring and usual care of heart failure: a systematic review.

457. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
     December 01, 2007 - After being treated for his worsening cardiomyopathy and renal failure, his mental status began to clear … Failure to initiate a system-wide search shortly after patient was noted to be missing Either lack of … clear policy regarding elopement or failure to follow available policy Failure to communicate event … The Missing Patient—Liability Liability can ensue when there is Negligent administration or failure … to administer medications Failure to notify the physician of changes in the patient’s condition Failure

458. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42612/psn-pdf
     July 05, 2016 - such as insufficient compliance with evidence-based guidelines, high rates of medication errors, and failure … https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events https://psnet.ahrq.gov/issue/failure-engage-hospitalized-elderly-patients-and-their-families-advance-care-planning … web-mm/right-regimen-wrong-cancer-patient-catches-medical-error https://psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something

459. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39004/psn-pdf
     April 04, 2011 - was a shift from the traditional culture of individual blame to one that investigated errors as the failure … behavior that should be managed through an accountability framework, with providers held accountable for failure … issue/patient-safety-and-just-culture-primer-health-care-executives https://psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands

460. Diagnosing Diagnostic Mistakes | PSNet
     psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
     April 30, 2014 - The lack of agreement among observers trying to discriminate pneumonia from heart failure on a chest … assessment of the processes—not the outcomes—of care.( 8 ) Issue #2 Overcalling error due to failure … is the failure to consider the consequences of competing diseases as the cause of a patient’s complaints … Can the clinical examination diagnose left-sided heart failure in adults? … to consider the spectrum of clinical presentations Failure to consider competing diagnoses