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Total Results: 7,834 records

Showing results for "failures".

121. Trainees' perceptions of patient safety practices: recounting failures of supervision. | PSNet
     psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision
     September 20, 2011 - Study Trainees' perceptions of patient safety practices: recounting failures of supervision … Trainees' perceptions of patient safety practices: recounting failures of supervision. … Trainees' perceptions of patient safety practices: recounting failures of supervision.

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40464/psn-pdf
     June 10, 2018 - Multiple latent failures align to allow a serious drug interaction to harm a patient. … https://psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient … Detailing a case in which latent failures led to patient harm, this article encourages health care … providers investigating adverse events to consider how both active and latent failures may line up to … https://psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient

123. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73637/psn-pdf
     August 25, 2021 - Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System … https://psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city … https://psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system … https://psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system

124. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36288/psn-pdf
     December 23, 2016 - Preventing adverse events caused by emergency electrical power system failures. … December 23, 2016 Preventing adverse events caused by emergency electrical power system failures. … https://psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system- failures … https://psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures … https://psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures

125. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43436/psn-pdf
     August 13, 2014 - Decreasing handoff-related care failures in children's hospitals. … Decreasing handoff-related care failures in children's hospitals. … https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-failures-childrens-hospitals Discontinuity … Following introduction of a structured handoff tool, handoff-related care failures declined and provider … Handoff- related care failures were defined as insufficient information transfer that affected the patient

126. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42473/psn-pdf
     August 13, 2013 - Surgical technology and operating-room safety failures: a systematic review of quantitative studies. … Surgical technology and operating-room safety failures: a systematic review of quantitative studies. … https://psnet.ahrq.gov/issue/surgical-technology-and-operating-room-safety-failures-systematic-review … - quantitative-studies Surgical equipment failures have been implicated as a significant contributor … https://psnet.ahrq.gov/issue/surgical-technology-and-operating-room-safety-failures-systematic-review-quantitative-studies

127. Improving patient safety by identifying latent failures in successful operations. | PSNet
     psnet.ahrq.gov/issue/improving-patient-safety-identifying-latent-failures-successful-operations
     September 15, 2010 - Study Improving patient safety by identifying latent failures in successful operations … Improving patient safety by identifying latent failures in successful operations. … Improving patient safety by identifying latent failures in successful operations.

128. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40473/psn-pdf
     July 02, 2011 - A systematic review of failures in handoff communication during intrahospital transfers. … A systematic review of failures in handoff communication during intrahospital transfers. … https://psnet.ahrq.gov/issue/systematic-review-failures-handoff-communication-during-intrahospital- … transfers Communication failures at the time of patient handoffs have been frequently implicated in … https://psnet.ahrq.gov/issue/systematic-review-failures-handoff-communication-during-intrahospital-transfers

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38621/psn-pdf
     February 18, 2011 - Process of care failures in breast cancer diagnosis. … Process of care failures in breast cancer diagnosis. … https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis Diagnostic errors have been … cases of recently diagnosed breast cancer to identify patient- and provider-related process of care failures … https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis https://psnet.ahrq.gov/issue

130. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36530/psn-pdf
     January 07, 2011 - Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. … Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. … psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and- attentional-failures … extended shifts were much more likely to report both significant preventable errors and attentional failures … /psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures

131. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40068/psn-pdf
     January 19, 2011 - Application of root cause analysis on malpractice claim files related to diagnostic failures. … Application of root cause analysis on malpractice claim files related to diagnostic failures. … //psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic- failures … https://psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic-failures … https://psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic-failures

132. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47427/psn-pdf
     June 19, 2019 - Failures in the respectful care of critically ill patients. … Failures in the Respectful Care of Critically Ill Patients. … https://psnet.ahrq.gov/issue/failures-respectful-care-critically-ill-patients Emotional and psychological … https://psnet.ahrq.gov/issue/failures-respectful-care-critically-ill-patients https://psnet.ahrq.gov/

133. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. | PSNet
     psnet.ahrq.gov/issue/mortality-and-morbidity-rounds-mmr-pathology-relative-contribution-cognitive-bias-vs-systems
     May 18, 2022 - Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures … October 19, 2022 Effect of reducing interns' weekly work hours on sleep and attentional failures

134. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44141/psn-pdf
     November 06, 2015 - Failures in communication through documents and documentation across the perioperative pathway. … Failures in communication through documents and documentation across the perioperative pathway. … https://psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across- perioperative-pathway … https://psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across-perioperative-pathway … https://psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across-perioperative-pathway

135. Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments. | PSNet
     psnet.ahrq.gov/issue/applicability-healthcare-failure-mode-and-effects-analysis-healthcare-epidemiology-evaluation
     October 19, 2022 - The mapped-out process then leads to identification of potential failures and the development of strategies … September 23, 2020 View More Related Resources Reducing failures … October 6, 2011 Assessing system failures in operating rooms and intensive care units … Use of failure mode and effects analysis for proactive identification of communication and handoff failures

136. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45912/psn-pdf
     May 09, 2017 - Medication reconciliation failures in children and young adults with chronic disease during intensive … Medication reconciliation failures in children and young adults with chronic disease during intensive … https://psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease … https://psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease-during-intensive … https://psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease-during-intensive

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45797/psn-pdf
     October 31, 2017 - Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures. … Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures. … https://psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care- failures … https://psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care-failures … https://psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care-failures

138. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34839/psn-pdf
     April 06, 2011 - Communication failures in the operating room: an observational classification of recurrent types and … Communication failures in the operating room: an observational classification of recurrent types and … https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent … https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and … https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

139. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45599/psn-pdf
     July 02, 2017 - Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency … Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency … https://psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care … https://psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care-emergency-and … https://psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care-emergency-and

140. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43093/psn-pdf
     August 12, 2014 - Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident … Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident … https://psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national … https://psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report … https://psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report