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Showing results for "failures".

161. 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

162. 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

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44876/psn-pdf
     February 10, 2016 - The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures … psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors- system-failures … psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors-system-failures … psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors-system-failures

164. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35802/psn-pdf
     January 02, 2017 - Reconciliation failures lead to medication errors. January 2, 2017 Santell JP. … Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9. … https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors Medication reconciliation … https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors https://psnet.ahrq.gov/primer

165. Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. | PSNet
     psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event-reach-patient
     March 14, 2023 - Newspaper/Magazine Article Latent and active failures perfectly align to allow a … Citation Text: Latent and active failures perfectly align to allow a preventable adverse event to reach … Copy URL Cite Citation Citation Text: Latent and active failures

166. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73426/psn-pdf
     June 23, 2021 - The majority of preventable adverse events are multifactorial in nature and are a result of system failures … Failures include differences in recording electronic health record notes and communication between providers … Investigations of all adverse events will help identify and correct system failures to improve patient

167. Participating in a multisite study exploring operational failures encountered by frontline nurses: lessons learned. | PSNet
     psnet.ahrq.gov/issue/participating-multisite-study-exploring-operational-failures-encountered-frontline-nurses
     July 05, 2017 - Commentary Participating in a multisite study exploring operational failures encountered … 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 … Download Citation Related Resources From the Same Author(s) Operational failures

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837975/psn-pdf
     August 31, 2022 - These events primarily involved communication failures, poor teamwork, and situational awareness failures … psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all-failures

169. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. | PSNet
     psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management-considerations-prevention
     May 27, 2011 - Study Classic An analysis of major errors and equipment failures … An analysis of major errors and equipment failures in anesthesia management: considerations for prevention … An analysis of major errors and equipment failures in anesthesia management: considerations for prevention … Related Resources An observational study of postoperative handoff standardization failures

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39729/psn-pdf
     September 20, 2011 - Contextual errors and failures in individualizing patient care: a multicenter study. … Contextual errors and failures in individualizing patient care: a multicenter study. … https://psnet.ahrq.gov/issue/contextual-errors-and-failures-individualizing-patient-care-multicenter-study … https://psnet.ahrq.gov/issue/contextual-errors-and-failures-individualizing-patient-care-multicenter-study

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37425/psn-pdf
     March 28, 2012 - Frequency and outcome of cervical cancer prevention failures in the United States. … Frequency and outcome of cervical cancer prevention failures in the United States. … https://psnet.ahrq.gov/issue/frequency-and-outcome-cervical-cancer-prevention-failures-united-states … https://psnet.ahrq.gov/issue/frequency-and-outcome-cervical-cancer-prevention-failures-united-states

172. 2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process. | PSNet
     psnet.ahrq.gov/issue/2014-annual-benchmarking-report-malpractice-risks-diagnostic-process
     September 26, 2012 - The authors use the data to explore cognitive and process failures that contributed to diagnostic … June 24, 2020 Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report … March 21, 2016 Malpractice Risks in Communication Failures: 2015 Annual Benchmarking

173. Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. | PSNet
     psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and-care-patient-chico-community-based-outpatient
     November 29, 2023 - This report examines organizational failures in responding to staff and clinical leaders’ concerns … 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

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49475/psn-pdf
     March 01, 2005 - By preventing these sorts of failures, IT applications reduce the need for such workarounds. … Indeed, preventing such failures is one reason that IT is now being deployed. … - based failures are infrequent but potentially severe. … Defenses against these failures are more difficult to devise and less likely to be robust.(11) More … Although failures involving IT are often regarded as human (operator) error, these failures actually

175. A systematic quantitative assessment of risks associated with poor communication in surgical care. | PSNet
     psnet.ahrq.gov/issue/systematic-quantitative-assessment-risks-associated-poor-communication-surgical-care
     August 11, 2010 - August 11, 2010 Failures in communication and information transfer across the surgical … July 6, 2012 An observational study of the frequency, severity, and etiology of failures … January 19, 2016 View More Related Resources Reducing failures … June 1, 2012 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

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40167/psn-pdf
     January 22, 2017 - Trainees' perceptions of patient safety practices: recounting failures of supervision. … Trainees' perceptions of patient safety practices: recounting failures of supervision. … https://psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision … https://psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision

177. Techno Trip | PSNet
     psnet.ahrq.gov/web-mm/techno-trip
     May 01, 2005 - By preventing these sorts of failures, IT applications reduce the need for such workarounds. … Indeed, preventing such failures is one reason that IT is now being deployed. … failures are infrequent but potentially severe. … Although failures involving IT are often regarded as human (operator) error, these failures actually … March 11, 2011 The role of automation in complex system failures.

178. Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. | PSNet
     psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-medical-center
     March 16, 2022 - Electronic health record (EHR) implementation failures cause major disruptions to care delivery that … July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

179. Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri. | PSNet
     psnet.ahrq.gov/issue/deficiencies-emergency-department-care-patient-who-died-suicide-john-cochran-division-va-st
     July 26, 2023 - This report shares recommendations to address leadership failures and other deficiencies including … July 5, 2023 Failures in Care Coordination and Reviewing a Patient's Death at the VA … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

180. Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021. | PSNet
     psnet.ahrq.gov/issue/comprehensive-healthcare-inspection-summary-report-evaluation-care-coordination-veterans
     July 27, 2022 - Care coordination failures reduce the effectiveness of communication, information transfer, and patient … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … July 26, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with