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Total Results: 8,190 records

Showing results for "failures".

161. Frequency and outcome of cervical cancer prevention failures in the United States. | PSNet
     psnet.ahrq.gov/issue/frequency-and-outcome-cervical-cancer-prevention-failures-united-states
     April 09, 2013 - Study Frequency and outcome of cervical cancer prevention failures in the United … Frequency and outcome of cervical cancer prevention failures in the United States. … Frequency and outcome of cervical cancer prevention failures in the United States.

162. 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

163. Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. | PSNet
     psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
     April 19, 2023 - Book/Report Failures in Care Coordination and Reviewing a Patient's Death at the … Citation Text: Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City … Linkedin Copy URL Cite Citation Citation Text: Failures … August 2, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

164. Active Error (or Active Failure) | PSNet
     psnet.ahrq.gov/glossary/active-error-or-active-failure
     September 13, 2021 - Active failures are sometimes referred to as errors at the sharp end, figuratively referring to a scalpel … Latent errors (or latent conditions), in contrast, refer to less apparent failures of organization or

165. Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation. | PSNet
     psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect-analysis-combined
     August 10, 2022 - Study Reducing failures in daily medical practice: healthcare failure mode and effect … Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with

166. A systems approach to analyzing and preventing hospital adverse events. | PSNet
     psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events
     March 30, 2022 - approach is based on the principle that accidents are not only the result of individual system component failures … Evolution of Root Cause Analysis February 26, 2025 Giving up learning from failures … An examination of learning from one's own failures in the context of heart surgeons. … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures

167. 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

168. 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

169. An evaluation of information transfer through the continuum of surgical care: a feasibility study. | PSNet
     psnet.ahrq.gov/issue/evaluation-information-transfer-through-continuum-surgical-care-feasibility-study
     December 21, 2014 - Communication failures are common in surgical care. … August 11, 2010 Failures in communication and information transfer across the surgical … February 9, 2011 An observational study of the frequency, severity, and etiology of failures … July 6, 2012 Surgical technology and operating-room safety failures: a systematic review

170. 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

171. Latent Error (or Latent Condition) | PSNet
     psnet.ahrq.gov/taxonomy/term/3488
     December 12, 2020 - Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed … Active failures, in contrast, are sometimes referred to as errors at the sharp end, or the personnel

172. 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

173. 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

174. Latent Error (or Latent Condition) | PSNet
     psnet.ahrq.gov/glossary/latent-error-or-latent-condition
     September 13, 2021 - Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed … Active failures, in contrast, are sometimes referred to as errors at the sharp end, or the personnel

175. 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

176. 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

177. 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

178. 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

179. 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

180. 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