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Showing results for "failure".

461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49475/psn-pdf
     March 01, 2005 - , information technology (IT) intended to bridge the gap in continuity actually contributed to the failure … But new technology is also a potent source of new forms of failure, especially when the human–computer … Instead, the failure occurred because the IT design was technology-centered rather than human-centered … This case demonstrates clearly, however, that failure can (and does!) arise from IT design. … This would have been an opportunity to capture failure in the making.

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34985/psn-pdf
     July 14, 2010 - psnet.ahrq.gov/issue/role-automation-complex-system-failures The authors present a case of automation failure … and discuss the role human practitioners played in recovering from the failure.

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45797/psn-pdf
     October 31, 2017 - In the majority of cases, they identified problems such as failure to elicit sufficient family history … Consistent with prior studies, failure to order laboratory testing and plan follow-up were associated

464. Techno Trip | PSNet
     psnet.ahrq.gov/web-mm/techno-trip
     May 01, 2005 - But new technology is also a potent source of new forms of failure, especially when the human–computer … Instead, the failure occurred because the IT design was technology-centered rather than human-centered … This case demonstrates clearly, however, that failure can (and does!) arise from IT design. … This would have been an opportunity to capture failure in the making. … Take-Home Points Adding IT does not eliminate failure but, instead, changes the type, frequency,

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46286/psn-pdf
     September 13, 2017 - https://psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method Failure … https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39736/psn-pdf
     April 03, 2017 - //psnet.ahrq.gov/issue/risk-and-event-assessment This issue contains several articles dedicated to Failure … https://psnet.ahrq.gov/issue/risk-and-event-assessment https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its

467. Reconciliation failures lead to medication errors. | PSNet
     psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors
     November 01, 2012 - Study Reconciliation failures lead to medication errors. Citation Text: Santell JP. Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

468. Systemic failures in health care oversight. | PSNet
     psnet.ahrq.gov/issue/systemic-failures-health-care-oversight
     July 05, 2006 - Commentary Systemic failures in health care oversight. Citation Text: Systemic failures in health care oversight. Campbell JL. Ga L Rev. 2024;58(2):737-802. Copy Citation Save Save to your library Print Download PDF Share Facebook Twi…

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35699/psn-pdf
     November 18, 2011 - The elements of the model are (1) prevention of failure, (2) identification and mitigation of failure

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49480/psn-pdf
     May 01, 2005 - The lack of agreement among observers trying to discriminate pneumonia from heart failure on a chest … for at least some of the inaccuracy in assessing the value of classic signs and symptoms of heart failure … The discussant claimed that the diagnosis was missed due in part to failure to note a small calcium … Can the clinical examination diagnose left-sided heart failure in adults? … to consider the spectrum of clinical presentations Failure to consider competing diagnoses Figure

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49581/psn-pdf
     March 21, 2009 - The immediate success or failure of a strategic change can be easily identified once the change has … However, the root cause of the error was actually a communication failure, because the physician failed … to communicate medications administered and patient outcomes during shift handoff; and (iii) failure … They should also consider conducting a failure mode and effect analysis to determine the potential for … failure and potential risk of harm.

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41711/psn-pdf
     September 26, 2012 - proactive risk assessment tool designed to address process concerns and to be more efficient than failure … ://psnet.ahrq.gov/issue/swift-new-tool-identifying-prospective-hazards https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35842/psn-pdf
     July 21, 2010 - psnet.ahrq.gov/issue/cognitive-versus-technical-debriefing-after-simulation-training After a simulated clinical failure … residents using either a technical debriefing on the subject matter or a cognitive debriefing on the failure

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41600/psn-pdf
     August 15, 2012 - discusses nursing surveillance and how it can help enhance monitoring of patient conditions to address failure … role-nursing-surveillance-keeping-patients-safe https://psnet.ahrq.gov/issue/review-current-and-emerging-approaches-address-failure-rescue

475. Acute Respiratory Arrest in Pregnancy | PSNet
     psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
     August 15, 2018 - rupture of membranes ( Figure ).( 1,2 ) As seen in this case, common errors in management include failure … shortness of breath and exacerbation in maternal BPs despite the use of antihypertensive medication, failure … to obtain the appropriate laboratory tests, and failure to hospitalize for close monitoring and timely … with twins was at very high risk for development of superimposed preeclampsia and congestive heart failure … of this visit, the patient should have been hospitalized for evaluation of possible congestive heart failure

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49545/psn-pdf
     September 01, 2007 - Coming Undone: Failure of Closure Device September 1, 2007 Baez-Escudero JL, Levine GN. … Coming Undone: Failure of Closure Device. PSNet [internet]. 2007. … https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device The Case A 65-year-old man underwent … patient, given the delay in the development of the hematoma, the likely cause of the bleeding was failure … Retroperitoneal hematomas can result from improper arterial puncture or failure to achieve adequate

477. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73417/psn-pdf
     June 23, 2021 - Failure classes include misunderstanding and misrecognition of words.

478. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36051/psn-pdf
     January 05, 2017 - issue/using-hfmea-assess-potential-patient-harm-tubing-misconnections The authors describe a health failure … using-hfmea-assess-potential-patient-harm-tubing-misconnections https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

479. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
     January 01, 2004 - Vasovagal 6.5 Congestive heart failure 5 Hyperventilation 3.3 Hypertensive crisis 2.2 Chest wall … -57 Diastolic murmur 28% 21-36 Pulse deficit 31% 24-39 Pericardial rub 6% 3-13 Congestive heart failure … Diastolic murmur 28% 21-36 Pulse deficit 31% 24-39 Pericardial rub 6% 3-13 Congestive heart failure … Vasovagal 6.5 Congestive heart failure 5 Hyperventilation 3.3 Hypertensive crisis 2.2 Chest wall … Vasovagal 6.5 Congestive heart failure 5 Hyperventilation 3.3 Hypertensive crisis 2.2 Chest wall

480. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41745/psn-pdf
     October 10, 2012 - Although direct communication of results to patients via email has been proposed as a strategy to prevent failure … email-communicating-results-diagnostic-medical-investigations-patients https://psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review