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Total Results: 8,190 records

Showing results for "failures".

141. 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

142. 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

143. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47059/psn-pdf
     May 16, 2018 - Participating in a multisite study exploring operational failures encountered by frontline nurses: lessons … Participating in a Multisite Study Exploring Operational Failures Encountered by Frontline Nurses: Lessons … https://psnet.ahrq.gov/issue/participating-multisite-study-exploring-operational-failures-encountered … https://psnet.ahrq.gov/issue/participating-multisite-study-exploring-operational-failures-encountered-frontline-nurses … https://psnet.ahrq.gov/issue/participating-multisite-study-exploring-operational-failures-encountered-frontline-nurses

144. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36078/psn-pdf
     July 03, 2013 - Inquiry into reporter's death finds multiple failures in care. July 3, 2013 Stout D. … https://psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care This article reports … The investigation uncovered a range of failures in emergency care and is described in a report available … https://psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care

145. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34794/psn-pdf
     November 18, 2015 - The model discussed focuses on two types of failures, which share equal importance in analysis but distinguish … The first, active failures, consists of mistakes made by providers in the delivery of care. … The second, latent failures, represents flaws in the systems of care. … The authors use a case example in anesthesia to illustrate how searching for active failures alone fails … analysis of past disasters has offered a useful model to differentiate provider from organizational failures

146. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44179/psn-pdf
     November 20, 2015 - Routine failures in the process for blood testing and the communication of results to patients in primary … Routine failures in the process for blood testing and the communication of results to patients in primary … https://psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients … https://psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients-primary-care-uk … https://psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients-primary-care-uk

147. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37066/psn-pdf
     October 03, 2011 - Improving patient safety by identifying latent failures in successful operations. … Improving patient safety by identifying latent failures in successful operations. … https://psnet.ahrq.gov/issue/improving-patient-safety-identifying-latent-failures-successful-operations … https://psnet.ahrq.gov/issue/improving-patient-safety-identifying-latent-failures-successful-operations

148. 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

149. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34985/psn-pdf
     July 14, 2010 - The role of automation in complex system failures. July 14, 2010 Perry SJ, Wears RL, Cook RI. … The role of automation in complex system failures. J Patient Saf. 2005;1(1):56-61. … https://psnet.ahrq.gov/issue/role-automation-complex-system-failures The authors present a case of automation … https://psnet.ahrq.gov/issue/role-automation-complex-system-failures

150. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42501/psn-pdf
     January 07, 2015 - Syndromic surveillance for health information system failures: a feasibility study. … Syndromic surveillance for health information system failures: a feasibility study. … https://psnet.ahrq.gov/issue/syndromic-surveillance-health-information-system-failures-feasibility-study … https://psnet.ahrq.gov/issue/syndromic-surveillance-health-information-system-failures-feasibility-study

151. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37873/psn-pdf
     June 16, 2009 - Dropping the baton: a qualitative analysis of failures during the transition from emergency department … Dropping the baton: a qualitative analysis of failures during the transition from emergency department … https://psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency … https://psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient … https://psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient

152. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864864/psn-pdf
     March 20, 2024 - Systemic failures in health care oversight. March 20, 2024 Campbell JL. … https://psnet.ahrq.gov/issue/systemic-failures-health-care-oversight Questions exist as to why practitioners … https://psnet.ahrq.gov/issue/systemic-failures-health-care-oversight https://psnet.ahrq.gov/issue/retrievals-reveals-painful-experiences-female-patients-are-often-ignored

153. 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

154. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/865308
     January 01, 2024 - Failures are inevitable in any industry, especially in one as complex as health care. … Organizations are encouraged to learn from failures and sustain improvement. … High reliability organizations consistently examine and learn from failures. … High reliability organizations consistently examine and learn from failures. … Organizations are encouraged to learn from failures and sustain improvement.

155. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41934/psn-pdf
     May 24, 2016 - Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on … https://psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures- … https://psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment … https://psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment

156. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846563/psn-pdf
     March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. … Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. … https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March … Impact of System Failures on Healthcare Workers https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers … Organizations can adopt a systematic approach to gather and analyze data, identify system failures,

157. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41051/psn-pdf
     February 20, 2012 - What do patients and relatives know about problems and failures in care? … What do patients and relatives know about problems and failures in care? … https://psnet.ahrq.gov/issue/what-do-patients-and-relatives-know-about-problems-and-failures-care Interviews … https://psnet.ahrq.gov/issue/what-do-patients-and-relatives-know-about-problems-and-failures-care https

158. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44169/psn-pdf
     November 06, 2015 - Weak oversight allows lab failures to put patients at risk. November 6, 2015 Gabler E. … https://psnet.ahrq.gov/issue/weak-oversight-allows-lab-failures-put-patients-risk Reporting on weaknesses … methods, this news article discusses patients' experiences with testing errors to illustrate how such failures … https://psnet.ahrq.gov/issue/weak-oversight-allows-lab-failures-put-patients-risk https://psnet.ahrq.gov

159. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46286/psn-pdf
     September 13, 2017 - Preventing blood transfusion failures: FMEA, an effective assessment method. … Preventing blood transfusion failures: FMEA, an effective assessment method. … https://psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method … https://psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method https

160. Communication failures in the operating room: an observational classification of recurrent types and effects. | PSNet
     psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and
     April 06, 2011 - Study Classic Communication failures in the operating room … 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