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Showing results for "failures".

101. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72865/psn-pdf
     March 17, 2021 - We can learn from our failures. March 17, 2021 Zeynep Tufekci. The Atlantic. … February 26, 2021 https://psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures … Failures in communication have impacts on patients, teams, organizations and society. … https://psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures https://

102. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854264/psn-pdf
     October 04, 2023 - Patient death tied to lack of proper escalation process for barcode scanning failures. … https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures … solution availability and staffing improvements are discussed to minimize opportunities for the systemic failures … https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures

103. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35174/psn-pdf
     June 23, 2009 - Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign … Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures to Detect the Foreign … https://psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures … case report, the authors discuss a series of errors and illustrate the concepts of active and latent failures … https://psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures-detect-foreign

104. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46139/psn-pdf
     September 23, 2017 - Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration … Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration … https://psnet.ahrq.gov/issue/impact-interruptions-distractions-and-cognitive-load-procedure-failures-and … https://psnet.ahrq.gov/issue/impact-interruptions-distractions-and-cognitive-load-procedure-failures-and-medication … https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing https://psnet.ahrq.gov

105. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34861/psn-pdf
     November 11, 2015 - When things go wrong: how health care organizations deal with major failures. … When things go wrong: how health care organizations deal with major failures. … https://psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures … The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the … https://psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures https

106. A 60-year-old man with delayed care for a renal mass. | PSNet
     psnet.ahrq.gov/issue/60-year-old-man-delayed-care-renal-mass
     January 31, 2024 - This article discusses a patient who experienced delays in care due to a myriad of system failures in … The invited discussant explores the causes of these failures and discusses situational awareness , improved … The fact that JAMA chose a clinical scenario focusing on systems failures mirrors past efforts in the … 24, 2011 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34073/psn-pdf
     February 17, 2011 - Effect of reducing interns' weekly work hours on sleep and attentional failures. … Effect of reducing interns' weekly work hours on sleep and attentional failures. … https://psnet.ahrq.gov/issue/effect-reducing-interns-weekly-work-hours-sleep-and-attentional-failures … that limiting intern work hours to less than 80 hours per week led to more sleep and less attentional failures … https://psnet.ahrq.gov/issue/effect-reducing-interns-weekly-work-hours-sleep-and-attentional-failures

108. Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room. | PSNet
     psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all-failures
     October 07, 2013 - Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in … The authors describe how systematically capturing small failures led to recognition of faulty processes … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in

109. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73416/psn-pdf
     June 23, 2021 - An observational study of postoperative handoff standardization failures. … An observational study of postoperative handoff standardization failures. … https://psnet.ahrq.gov/issue/observational-study-postoperative-handoff-standardization-failures Standardized … https://psnet.ahrq.gov/issue/observational-study-postoperative-handoff-standardization-failures https

110. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73403/psn-pdf
     June 16, 2021 - Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas … https://psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville … https://psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville-arkansas-va … https://psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville-arkansas-va

111. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/843321/psn-pdf
     February 01, 2023 - Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. … https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event … https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event-reach-patient … https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event-reach-patient

112. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/849615/psn-pdf
     May 31, 2023 - Clinical Investigation Booking Systems Failures: Written Communications in Community Languages. … https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications- … https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-community-languages … https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-community-languages

113. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43809/psn-pdf
     February 25, 2015 - Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures … psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all- failures … The authors describe how systematically capturing small failures led to recognition of faulty processes … psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all-failures

114. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44767/psn-pdf
     January 20, 2016 - Applying psychological theory to understanding failures in modern healthcare settings. … Applying psychological theory to understanding failures in modern healthcare settings. … https://psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding- failures-modern … concepts from psychology, including theories related to behavior and cognition, to understand why care failures … https://psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern

115. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40365/psn-pdf
     February 12, 2014 - https://psnet.ahrq.gov/issue/strategies-learning-failure Failures are inevitable in any industry, especially … The ability to learn from failures is a crucial characteristic of high reliability organizations, and … This article draws a distinction between preventable failures in predictable operations—which are largely … due to slips, and can be prevented by interventions such as checklists—and unavoidable failures in … The author, who has extensively analyzed high- profile failures in many industries, recommends that

116. Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. | PSNet
     psnet.ahrq.gov/issue/care-and-oversight-deficiencies-related-multiple-homicides-louis-johnson-va-medical-center
     February 10, 2021 - Health care system failures can enable unrecognized, persistent criminal behavior. … May 1, 2015 Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … May 3, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

117. Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona. | PSNet
     psnet.ahrq.gov/issue/deficiencies-quality-management-processes-and-delays-communication-test-results-and-follow
     March 01, 2023 - Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … April 26, 2006 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … Improving Diagnostic Safety and Quality April 26, 2023 Multiple Failures

118. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41469/psn-pdf
     October 19, 2012 - Deconstructing intraoperative communication failures. … Deconstructing intraoperative communication failures. … https://psnet.ahrq.gov/issue/deconstructing-intraoperative-communication-failures Video recordings of … six complex surgical procedures revealed that communication failures were frequent, especially in discussions … https://psnet.ahrq.gov/issue/deconstructing-intraoperative-communication-failures https://psnet.ahrq.gov

119. Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure. | PSNet
     psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists-allowing
     December 14, 2022 - Study Using trainee failures to enhance learning: a qualitative study of pediatric … Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing … Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing

120. Syndromic surveillance for health information system failures: a feasibility study. | PSNet
     psnet.ahrq.gov/issue/syndromic-surveillance-health-information-system-failures-feasibility-study
     November 03, 2015 - Study Syndromic surveillance for health information system failures: a feasibility … Syndromic surveillance for health information system failures: a feasibility study. … Syndromic surveillance for health information system failures: a feasibility study. … November 2, 2010 A systematic review of failures in handoff communication during intrahospital