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Showing results for "failure".

281. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50574/psn-pdf
     October 23, 2019 - Occupational stress and cognitive failure of nurses and associations with on self-reported adverse events … Occupational stress and cognitive failure of nurses and associations with self-reported adverse events … https://psnet.ahrq.gov/issue/occupational-stress-and-cognitive-failure-nurses-and-associations-self- … https://psnet.ahrq.gov/issue/occupational-stress-and-cognitive-failure-nurses-and-associations-self-reported-adverse … https://psnet.ahrq.gov/issue/occupational-stress-and-cognitive-failure-nurses-and-associations-self-reported-adverse

282. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853244/psn-pdf
     September 06, 2023 - This article highlights five patient safety risks during pediatric perioperative blood management (failure … to recognize and treat preoperative anemia, failure to obtain informed consent regarding perioperative … blood management, failure to consider specific intraoperative blood conservation techniques in children … , failure to recognize massive hemorrhage, failure to prevent unnecessary transfusion).

283. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60648/psn-pdf
     July 01, 2020 - Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives … Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives … https://psnet.ahrq.gov/issue/chronicle-pandemic-foretold-learning-covid-19-failure-next-outbreak-arrives … This article examines the COVID-19 pandemic through a system failure lens. … https://psnet.ahrq.gov/issue/chronicle-pandemic-foretold-learning-covid-19-failure-next-outbreak-arrives

284. Power to the patient: Design and Test of Closed-Loop Interactive IT for Geriatric Heart Failure Self-Care - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r21hs025232-holden-final-report-2019.pdf
     January 01, 2019 - Scenario 3 – Failure post-mortem and reflection. … Modeling Personas for Older Adults with Heart Failure. … Circulation: Heart Failure. 2010;3:97-103. 7. Heart Failure Society of America (HFSA). … A situation-specific theory of heart failure self-care. … Journal of Cardiac Failure. 2011;17:664-9. 26.

285. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40060/psn-pdf
     December 15, 2010 - Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures. … Failure Mode and Effects Analysis. J Patient Saf. 2010;6(4):210-215. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures

286. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60525/psn-pdf
     May 27, 2020 - Public sector organizational failure: a study of collective denial in the UK national health service … Public sector organizational failure: a study of collective denial in the UK national health service … https://psnet.ahrq.gov/issue/public-sector-organizational-failure-study-collective-denial-uk-national-health … https://psnet.ahrq.gov/issue/public-sector-organizational-failure-study-collective-denial-uk-national-health-service … https://psnet.ahrq.gov/issue/public-sector-organizational-failure-study-collective-denial-uk-national-health-service

287. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838012/psn-pdf
     September 07, 2022 - The physiology of failure: identifying risk factors for mortality in emergency general surgery patients … The physiology of failure: identifying risk factors for mortality in emergency general surgery patients … https://psnet.ahrq.gov/issue/physiology-failure-identifying-risk-factors-mortality-emergency-general-surgery … https://psnet.ahrq.gov/issue/physiology-failure-identifying-risk-factors-mortality-emergency-general-surgery-patients … https://psnet.ahrq.gov/issue/physiology-failure-identifying-risk-factors-mortality-emergency-general-surgery-patients

288. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50686/psn-pdf
     January 01, 2020 - 'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure … ‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing trainee failure … whatever-you-cut-i-can-fix-it-clinical-supervisors-interview-accounts-allowing- trainee This qualitative study explored physicians experience allowing for failure … Allowing supervised failure was perceived to be an important element of trainee development and was … whatever-you-cut-i-can-fix-it-clinical-supervisors-interview-accounts-allowing-trainee https://psnet.ahrq.gov/issue/strategies-learning-failure

289. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73630/psn-pdf
     August 25, 2021 - Towards safer healthcare: qualitative insights from a process view of organisational learning from failure … Towards safer healthcare: qualitative insights from a process view of organisational learning from failure … psnet.ahrq.gov/issue/towards-safer-healthcare-qualitative-insights-process-view-organisational- learning-failure … psnet.ahrq.gov/issue/towards-safer-healthcare-qualitative-insights-process-view-organisational-learning-failure … psnet.ahrq.gov/issue/towards-safer-healthcare-qualitative-insights-process-view-organisational-learning-failure

290. Learn-From-Defects-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
     May 01, 2017 - Sensemaking calls for staff to work through the failure, identifying the latent and active contributors … A knowledge-based failure happens when a person is unable to apply existing knowledge to new situations … To accomplish the same work, Sensemaking uses the Discovery Form, the Root Cause Analysis, the Failure … the failure. … On this worksheet, you see both a failure and a recovery side.

291. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/844047/psn-pdf
     February 08, 2023 - Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure … Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure … In this study, pediatric hospitalists describe potential benefits and risks of allowing failure, the … process of allowing or interrupting failure, and how they decide to allow failure to happen.

292. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73976/psn-pdf
     October 20, 2021 - A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia … A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia … https://psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases … https://psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia … https://psnet.ahrq.gov/issue/retrospective-analysis-demonstrates-failure-document-key-comorbid-diseases-anesthesia

293. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61119/psn-pdf
     November 11, 2020 - Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution. … Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution. … https://psnet.ahrq.gov/issue/misdiagnosis-and-failure-diagnose-emergency-care-causes-and-empathy- solution … https://psnet.ahrq.gov/issue/misdiagnosis-and-failure-diagnose-emergency-care-causes-and-empathy-solution … https://psnet.ahrq.gov/issue/misdiagnosis-and-failure-diagnose-emergency-care-causes-and-empathy-solution

294. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867845/psn-pdf
     February 26, 2025 - technique to analyze numerous patient safety reports, aggregate proactive risk assessments (e.g., Failure … Bender and Steve Kulju, two members of the NCPS team, report that NCPS piloted CPRA in 2020 using Failure … The flow diagram summarizes the process and reveals a list of all failure modes. … Approximately one- third of failure modes (n=14) were identified by at least one facility, and about … three-quarters of failure modes (n=32) were not analyzed by any of the 3 facilities in the proactive

295. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60593/psn-pdf
     June 17, 2020 - Failure to follow medication changes made at hospital discharge is associated with adverse events in … Failure to follow medication changes made at hospital discharge is associated with adverse events in … https://psnet.ahrq.gov/issue/failure-follow-medication-changes-made-hospital-discharge-associated- adverse-events … https://psnet.ahrq.gov/issue/failure-follow-medication-changes-made-hospital-discharge-associated-adverse-events … -30-days https://psnet.ahrq.gov/issue/failure-follow-medication-changes-made-hospital-discharge-associated-adverse-events

296. Sustainability and the Premortem Tool: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-slides.html
     December 01, 2017 - Brainstorm contributing factors that led to this failure. … Slide 8: Premortem Exercise Step 2 Generate the reasons for this failure to sustain improvements … Spend 10 minutes recording the reasons that could cause this failure. … Slide 10: Premortem Exercise Step 4 Prioritize your list of potential reasons for failure. … Target the potential risks for failure to achieve sustainment goals.

297. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50832/psn-pdf
     January 01, 2021 - Preventing critical failure. … Preventing critical failure. … https://psnet.ahrq.gov/issue/preventing-critical-failure-can-routinely-collected-data-be-repurposed-predict … https://psnet.ahrq.gov/issue/preventing-critical-failure-can-routinely-collected-data-be-repurposed-predict-avoidable … https://psnet.ahrq.gov/issue/preventing-critical-failure-can-routinely-collected-data-be-repurposed-predict-avoidable

298. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/842416/psn-pdf
     January 11, 2023 - A failure in the medication delivery system-how disclosure and systems investigation improve patient … A failure in the medication delivery system—how disclosure and systems investigation improve patient … https://psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation … https://psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation-improve-patient … https://psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation-improve-patient

299. Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery. | PSNet
     psnet.ahrq.gov/issue/using-proactive-risk-assessment-hfmea-improve-patient-safety-and-quality-associated
     September 19, 2016 - Researchers used failure mode and effects analysis to examine intraocular lens implantation. … They report uncovering many potential failure modes or safety vulnerabilities and extensive variation … October 18, 2023 Using Health Care Failure Mode and Effect Analysis: the VA National … September 13, 2023 Reducing failures in daily medical practice: healthcare failure mode … October 24, 2018 Applicability of Healthcare Failure Mode and Effects Analysis to healthcare

300. Sustainability and the Premortem Tool: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-fac-notes.html
     December 01, 2017 - The idea is to brainstorm for possible failure points in order to address them. … In step three, identify the concerns that would be raised by each identified potential cause for failure … Use the scale shown here to rank your team’s concerns about each failure. … Ask: What can your team implement to avoid or mitigate these failure points? … Say: Target potential risks for failure in order to achieve success in sustainment.