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Showing results for "failure".

401. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61031/psn-pdf
     October 14, 2020 - This special section discusses how examination tools such as failure mode and effect analysis and root … cause analysis may be amended to optimize how lessons can be drawn from failure to inform improvement … psnet.ahrq.gov/perspective/rethinking-root-cause-analysis https://psnet.ahrq.gov/issue/strategies-learning-failure

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36554/psn-pdf
     September 27, 2010 - Communication failure: basic components, contributing factors, and the call for structure. … Communication failure: basic components, contributing factors, and the call for structure. … https://psnet.ahrq.gov/issue/communication-failure-basic-components-contributing-factors-and-call- structure … https://psnet.ahrq.gov/issue/communication-failure-basic-components-contributing-factors-and-call-structure … https://psnet.ahrq.gov/issue/communication-failure-basic-components-contributing-factors-and-call-structure

403. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34923/psn-pdf
     February 27, 2009 - Failure mode and effects analysis application to critical care medicine. … Failure mode and effects analysis application to critical care medicine. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-application-critical-care-medicine This … article provides background on failure mode and effects analysis (FMEA) and reviews both the positive … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-application-critical-care-medicine https

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37242/psn-pdf
     September 12, 2016 - Failure-to-rescue: comparing definitions to measure quality of care. … Failure-to-rescue: comparing definitions to measure quality of care. … https://psnet.ahrq.gov/issue/failure-rescue-comparing-definitions-measure-quality-care This study examined … the effectiveness of three different failure to rescue definitions in evaluating the quality of care … https://psnet.ahrq.gov/issue/failure-rescue-comparing-definitions-measure-quality-care https://psnet.ahrq.gov

405. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38469/psn-pdf
     March 11, 2009 - Post-discharge medication reviews for patients with heart failure: a pilot study. … Post-discharge medication reviews for patients with heart failure: a pilot study. … https://psnet.ahrq.gov/issue/post-discharge-medication-reviews-patients-heart-failure-pilot-study A … successfully implemented in order to improve postdischarge care for patients with congestive heart failure … https://psnet.ahrq.gov/issue/post-discharge-medication-reviews-patients-heart-failure-pilot-study https

406. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34601/psn-pdf
     January 26, 2009 - Strategies and tips for maximizing failure mode and effect analysis in your organization. … https://psnet.ahrq.gov/issue/strategies-and-tips-maximizing-failure-mode-and-effect-analysis-your- organization … Risk managers provide pearls from their experience, applying failure mode and effects analysis (FMEA … https://psnet.ahrq.gov/issue/strategies-and-tips-maximizing-failure-mode-and-effect-analysis-your-organization … https://psnet.ahrq.gov/issue/strategies-and-tips-maximizing-failure-mode-and-effect-analysis-your-organization

407. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41663/psn-pdf
     January 31, 2013 - Physician patient communication failure facilitates medication errors in older polymedicated patients … Physician patient communication failure facilitates medication errors in older polymedicated patients … https://psnet.ahrq.gov/issue/physician-patient-communication-failure-facilitates-medication-errors-older … https://psnet.ahrq.gov/issue/physician-patient-communication-failure-facilitates-medication-errors-older-polymedicated … https://psnet.ahrq.gov/issue/physician-patient-communication-failure-facilitates-medication-errors-older-polymedicated

408. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41588/psn-pdf
     August 15, 2012 - Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with … Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with … https://psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation- failure-patients-trauma … https://psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-failure-patients-trauma … https://psnet.ahrq.gov/issue/implementation-evidence-based-extubation-checklist-reduce-extubation-failure-patients-trauma

409. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39873/psn-pdf
     January 22, 2017 - A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician … A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician … https://psnet.ahrq.gov/issue/proactive-risk-avoidance-system-using-failure-mode-and-effects-analysis- … raised by a physician with a common last name during executive walk rounds, the institution conducted a failure … https://psnet.ahrq.gov/issue/proactive-risk-avoidance-system-using-failure-mode-and-effects-analysis-same-name-physician

410. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38889/psn-pdf
     April 01, 2010 - Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation … Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation … https://psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry … https://psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry-system … https://psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry-system

411. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34991/psn-pdf
     June 22, 2009 - Use of failure mode and effects analysis in improving the safety of i.v. drug administration. … Use of failure mode and effects analysis in improving the safety of i.v. drug administration. … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration … The authors used failure mode and effects analysis (FMEA) to identify dosing and administration errors … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration

412. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49544/psn-pdf
     September 01, 2007 - Heart Failure Society of America. HFSA 2006 comprehensive heart failure practice guideline. … Clinical Performance Measures) endorsed by the Heart Failure Society of America. … Discharge education improves clinical outcomes in patients with chronic heart failure. … With The Guidelines (GWTG) heart failure program. … Joint Commission/CMS Heart Failure Inpatient Performance Measure Descriptions.

413. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50722/psn-pdf
     December 04, 2019 - 20 years later: to err is a leadership failure. December 4, 2019 Castellucci M, Meyer H. … https://psnet.ahrq.gov/issue/20-years-later-err-leadership-failure This special segment shares commentaries … https://psnet.ahrq.gov/issue/20-years-later-err-leadership-failure https://psnet.ahrq.gov/issue/err-human-building-safer-health-system

414. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36838/psn-pdf
     April 19, 2011 - A very public failure: lessons for quality improvement in healthcare organisations from the Bristol … A very public failure: lessons for quality improvement in healthcare organisations from the Bristol … https://psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations … https://psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations-bristol-royal … https://psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations-bristol-royal

415. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44910/psn-pdf
     March 09, 2016 - Systematically Identified Failure Is the Route to a Successful Health System. … https://psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system Identifying … Exploring challenges to system-level efforts to learn from failure in health care, articles in this … https://psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system https:/ … learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and https://psnet.ahrq.gov/issue/strategies-learning-failure

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40620/psn-pdf
     July 22, 2011 - The role of documents and documentation in communication failure across the perioperative pathway. … The role of documents and documentation in communication failure across the perioperative pathway. … https://psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across- perioperative-pathway … https://psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across-perioperative-pathway … https://psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across-perioperative-pathway

417. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40195/psn-pdf
     February 02, 2011 - Mock trial at 2009 RSNA annual meeting: jury exonerates radiologist for failure to communicate abnormal … Mock trial at 2009 RSNA annual meeting: Jury exonerates radiologist for failure to communicate abnormal … https://psnet.ahrq.gov/issue/mock-trial-2009-rsna-annual-meeting-jury-exonerates-radiologist-failure- … https://psnet.ahrq.gov/issue/mock-trial-2009-rsna-annual-meeting-jury-exonerates-radiologist-failure-communicate-abnormal … https://psnet.ahrq.gov/issue/mock-trial-2009-rsna-annual-meeting-jury-exonerates-radiologist-failure-communicate-abnormal

418. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866080/psn-pdf
     June 05, 2024 - giving-learning-failures-examination-learning-ones-own-failures-context-heart- surgeons Learning from failure … giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons https://psnet.ahrq.gov/issue/strategies-learning-failure

419. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43915/psn-pdf
     September 27, 2017 - The quality of hospital work environments and missed nursing care is linked to heart failure readmissions … The quality of hospital work environments and missed nursing care is linked to heart failure readmissions … https://psnet.ahrq.gov/issue/quality-hospital-work-environments-and-missed-nursing-care-linked-heart- failure-readmissions … ' work environment and more frequent reports of missed care also had higher readmissions for heart failure … https://psnet.ahrq.gov/issue/quality-hospital-work-environments-and-missed-nursing-care-linked-heart-failure-readmissions

420. Hyponatremia Secondary to Home Parenteral Nutrition Error | PSNet
     psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
     May 27, 2020 - The Commentary By Kelly Haas, MD, and Andrew Lee, PharmD Pediatric intestinal failure occurs … Pediatric Intestinal Failure. N Engl J Med. 2017;377(7):666-675. … Long-term outcomes of pediatric intestinal failure.  … Coordinated interdisciplinary management of pediatric intestinal failure: a 2-year review. … Clinical outcomes in pediatric intestinal failure: a meta-analysis and meta-regression.