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Showing results for "failure".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38797/psn-pdf
    July 22, 2009 - Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic … Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic … https://psnet.ahrq.gov/issue/failure-recognize-newly-identified-aortic-dilations-health-care-system- … https://psnet.ahrq.gov/issue/failure-recognize-newly-identified-aortic-dilations-health-care-system-advanced-electronic … https://psnet.ahrq.gov/issue/failure-recognize-newly-identified-aortic-dilations-health-care-system-advanced-electronic

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36413/psn-pdf
    July 13, 2010 - Implications of the failure to identify high-risk electrocardiogram findings for the quality of care … Implications of the failure to identify high-risk electrocardiogram findings for the quality of care … https://psnet.ahrq.gov/issue/implications-failure-identify-high-risk-electrocardiogram-findings-quality-care … https://psnet.ahrq.gov/issue/implications-failure-identify-high-risk-electrocardiogram-findings-quality-care-patients … https://psnet.ahrq.gov/issue/implications-failure-identify-high-risk-electrocardiogram-findings-quality-care-patients

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47751/psn-pdf
    May 01, 2019 - Heart Failure: The Decline of a Historic Transplant Program. … https://psnet.ahrq.gov/issue/heart-failure-decline-historic-transplant-program This news investigation … https://psnet.ahrq.gov/issue/heart-failure-decline-historic-transplant-program https://psnet.ahrq.gov

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43681/psn-pdf
    June 03, 2016 - Learning from failure: the need for independent safety investigation in healthcare. … Learning from failure: the need for independent safety investigation in healthcare. … https://psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare High … https://psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare https: … //psnet.ahrq.gov/issue/strategies-learning-failure https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39975/psn-pdf
    March 03, 2011 - Communication failure in the operating room. … Communication failure in the operating room. … https://psnet.ahrq.gov/issue/communication-failure-operating-room Communication failures are a well-characterized … to assess the incidence, types, and consequences of surgical communication problems, and found that failure … https://psnet.ahrq.gov/issue/communication-failure-operating-room https://psnet.ahrq.gov/issue/operating-room-teamwork-among-physicians-and-nurses-teamwork-eye-beholder

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47287/psn-pdf
    December 19, 2018 - Shifting and sharing: academic physicians' strategies for navigating underperformance and failure. … Shifting and Sharing: Academic Physicians' Strategies for Navigating Underperformance and Failure. … psnet.ahrq.gov/issue/shifting-and-sharing-academic-physicians-strategies-navigating- underperformance-and-failure … psnet.ahrq.gov/issue/shifting-and-sharing-academic-physicians-strategies-navigating-underperformance-and-failure … psnet.ahrq.gov/issue/shifting-and-sharing-academic-physicians-strategies-navigating-underperformance-and-failure

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47304/psn-pdf
    October 24, 2018 - Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. … Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. … https://psnet.ahrq.gov/issue/mind-overlap-how-system-problems-contribute-cognitive-failure-and- diagnostic-errors … https://psnet.ahrq.gov/issue/mind-overlap-how-system-problems-contribute-cognitive-failure-and-diagnostic-errors … https://psnet.ahrq.gov/issue/mind-overlap-how-system-problems-contribute-cognitive-failure-and-diagnostic-errors

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34083/psn-pdf
    June 30, 2011 - Handoff strategies in settings with high consequences for failure: lessons for health care operations … Handoff strategies in settings with high consequences for failure: lessons for health care operations … https://psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care … https://psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations … https://psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848365/psn-pdf
    May 03, 2023 - issue/value-improving-patient-safety-health-economic-considerations-rapid- response-systems-rapid Failure … the authors used health economics methods to understand the health economic impacts associated with failure … value-improving-patient-safety-health-economic-considerations-rapid-response-systems-rapid https://psnet.ahrq.gov/primer/failure-rescue

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72677/psn-pdf
    January 27, 2021 - psnet.ahrq.gov/issue/implementation-science-approach-promote-optimal-implementation-adoption- use-and-spread Failure … efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue … implementation-science-approach-promote-optimal-implementation-adoption-use-and-spread https://psnet.ahrq.gov/primer/failure-rescue

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49867/psn-pdf
    July 02, 2019 - 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 … and ascites.(5) Thiazides can help reduce water retention in patients with mild congestive heart failure … 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

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36219/psn-pdf
    October 18, 2010 - Risk, society and system failure. October 18, 2010 Scalliet P. Risk, society and system failure. … https://psnet.ahrq.gov/issue/risk-society-and-system-failure The author discusses why large scale accidents … https://psnet.ahrq.gov/issue/risk-society-and-system-failure

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43363/psn-pdf
    September 12, 2016 - Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. … Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. … https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative … https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study … https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45710/psn-pdf
    December 22, 2017 - Our current approach to root cause analysis: is it contributing to our failure to improve patient safety … Our current approach to root cause analysis: is it contributing to our failure to improve patient safety … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33959/psn-pdf
    January 17, 2012 - Healthcare Failure Mode and Effect Analysis. … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis These materials provide an … introduction to the purpose of healthcare failure mode and effect analysis (HFMEA), the steps of the … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis

  16. Spotlight Case September 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
    September 01, 2003 - of message transmission Failure of message reception Failure of message acknowledgment Failure … of Message Transmission Failure to inform ICU doctor fails to inform anesthesiologist doing nasal … to act on message Distraction leads to delay or failure to give requested drug Failure of Message … that heparin be administered Failure to acknowledge understanding Team member responds with “uh-huh … ” rather than explicit read-back of instructions given Failure to state when action taken Requested

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846759/psn-pdf
    March 29, 2023 - The primary contributing factors to wrong-site surgery was failure to follow policy or protocols (such … as failure to follow the Universal Protocol) and failure to review medical records.

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49856/psn-pdf
    March 01, 2019 - Only one-third of patients who required intubation were considered high risk for extubation failure … , heart failure, or encephalopathy instead of stridor). … There is currently no consensus on optimal therapies to prevent extubation failure. … Risk factors for extubation failure in patients following a successful spontaneous breathing trial. … The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156(2 pt 1):459-465.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36124/psn-pdf
    June 15, 2011 - System failure versus personal accountability--the case for clean hands. … System failure versus personal accountability--the case for clean hands. … https://psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands The author … https://psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands https://psnet.ahrq.gov

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38879/psn-pdf
    March 02, 2011 - The competent surgeon: individual accountability in the era of "systems" failure. … The competent surgeon: individual accountability in the era of "systems" failure. … https://psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure Discussing … https://psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
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