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digital.ahrq.gov/program-overview/research-stories/improving-safety-postoperative-handoff-communication-telemedicine
January 01, 2023 - Joanna Abraham and her team at Washington University recognize that care transition failures can lead
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/guillen-s-et-al-2002
January 01, 2002 - On the contrary, technical aspects are rated lower because failures in the connection appeared in three
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digital.ahrq.gov/sites/default/files/docs/page/2006PattersonGeisWears_051611comp.pdf
March 01, 2006 - and Wears, 2000
Improving Teamwork and
Communication
To Improve Patient Safety
Communication failures … Early research in
commercial aviation
crashes demonstrated
that failures in
“leadership,
communication
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digital.ahrq.gov/ahrq-funded-projects/first-do-no-harm-using-health-information-technology-reduce-use-preventive
January 01, 2023 - discussion: What have we learned from previous experience with clinical decision support – successes, failures
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digital.ahrq.gov/ahrq-funded-projects/knowledge-engineering-decision-support-osteoporosis/annual-summary/2012
January 01, 2012 - LaFleur is working toward her long-term career goal of identifying and preventing drug-therapy failures
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digital.ahrq.gov/ahrq-funded-projects/knowledge-engineering-decision-support-osteoporosis/annual-summary/2010
January 01, 2010 - LaFleur will further her long-term career goal of identifying and preventing drug-therapy failures in
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digital.ahrq.gov/sites/default/files/docs/publication/Parisetal_HFES2008.pdf
January 01, 2008 - Some system errors may go unreported
because latent errors, such as communication failures, are not … “Preventing Medication
Errors,” the Institute of Medicine (IOM) found that latent
communication failures … healthcare community to “look beyond blaming individuals
and focus on the multiple underlying system failures
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digital.ahrq.gov/ahrq-funded-projects/evidence-based-contingency-planning-electronic-health-record-downtime
January 01, 2023 - It may be caused by system failures; software or hardware issues; interruptions to internet connectivity
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digital.ahrq.gov/ahrq-funded-projects/knowledge-engineering-decision-support-osteoporosis/annual-summary/2011
January 01, 2011 - LaFleur will further her long-term career goal of identifying and preventing drug-therapy failures in
-
digital.ahrq.gov/sites/default/files/docs/citation/r01hs022305-manojlovich-final-report-2019.pdf
January 01, 2019 - Scope: Communication failures between physicians and nurses are one of the most common
causes of adverse … record, computerized provider order entry,
email, and pagers) may help reduce some communication failures … Using incident reports to assess
communication failures and patient outcomes. … Communication failures: An insidious contributor to
medical mishaps.
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digital.ahrq.gov/medical-condition/congestive-heart-failure-chf
January 01, 2024 - Congestive Heart Failure (CHF)
Comparison of short-term health care utilization between telemedicine-delivered vs in-person care visits for heart failure.
Citation
Casey SD, Sax DR, Mark DG, Rana JS, Solomon MD, Huang J, Reed ME. Comparison of short-term health care utilizatio…
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digital.ahrq.gov/ahrq-funded-projects/using-information-technology-it-improve-medication-safety-rural-elders/annual-summary/2008
January 01, 2008 - projects that attempt to create a health information exchange, the RxSafe project had both successes and failures
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digital.ahrq.gov/ahrq-funded-projects/electronic-records-improve-care-children/annual-summary/2009
January 01, 2009 - Important steps were taken toward remedying those failures.
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digital.ahrq.gov/ahrq-funded-projects/health-information-technology-heart-failure-care
January 01, 2023 - Health Information Technology in Heart Failure Care
Project Final Report ( PDF , 321.58 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. N…
-
digital.ahrq.gov/ahrq-funded-projects/metro-dc-health-information-exchange-medhix/annual-summary/2009
January 01, 2009 - about the benefits, risks, opportunities, priorities, implementation strategies, national successes and failures
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs021590-ralston-final-report-2017.pdf
January 01, 2017 - systems of home
calendar management, including the common use of multiple calendars within a home, and
failures … Based on participants’
experiences, failures in remembering to perform self-management activities should … be viewed
as system failures rather individual failures.
-
digital.ahrq.gov/ahrq-funded-projects/power-patient-design-and-test-closed-loop-interactive-it-geriatric-heart
January 01, 2023 - Power to the Patient: Design and Test of Closed-Loop Interactive IT for Geriatric Heart Failure Self-Care
Project Final Report ( PDF , 925.1 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, …
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digital.ahrq.gov/sites/default/files/docs/page/2006Richards_051611comp.pdf
June 05, 2006 - physician
master file updates via
intranet form as needed
Physician master file updates
lead to fewer failures
-
digital.ahrq.gov/sites/default/files/docs/citation/r21hs022586-lacson-final-report-2017.pdf
January 01, 2017 - transitioning to ambulatory care from the
emergency department (ED) and inpatient settings, can exacerbate failures … unclear, and this transfer of responsibility
between acute care and ambulatory clinicians may exacerbate failures … to ambulatory care sites from
the emergency department (ED) and inpatient settings, can exacerbate failures
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs022087-singh-final-report-2018.pdf
January 01, 2018 - Scope: Delayed diagnoses resulting from test result communication failures (“missed” test
results) are … and specifically highlighted the importance of both diagnostic errors and test
result communication failures … attention has focused on these critical test results.(20, 21) However,
research highlights communication failures … the hazard potential for
errors at each step in the EHR test result follow-up process and isolated failures … Significance:
Delayed diagnoses resulting from test result communication failures is an important topic