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Total Results: 7,834 records

Showing results for "failures".

181. The potential for improved teamwork to reduce medical errors in the emergency department. | PSNet
     psnet.ahrq.gov/issue/potential-improved-teamwork-reduce-medical-errors-emergency-department
     July 07, 2021 - This article aims to introduce emergency department communities to teamwork systems, teamwork failures … that commonly occur, and the consequences of identified failures. … Discussion includes retrospective analysis of more than 50 incidents suggesting that nearly nine teamwork failures

182. The perfect storm: exam of a medical error and factors contributing to its possible escalation. | PSNet
     psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation
     October 20, 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 … Investigations of all adverse events will help identify and correct system failures to improve patient

183. Contextual errors and failures in individualizing patient care: a multicenter study. | PSNet
     psnet.ahrq.gov/issue/contextual-errors-and-failures-individualizing-patient-care-multicenter-study
     October 29, 2012 - Study Classic Contextual errors and failures in individualizing … Contextual errors and failures in individualizing patient care: a multicenter study. … Contextual errors and failures in individualizing patient care: a multicenter study.

184. Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts. | PSNet
     psnet.ahrq.gov/issue/improving-patient-safety-governance-and-systems-through-learning-successes-and-failures
     May 08, 2017 - Improving patient safety governance and systems through learning from successes and failures … Improving patient safety governance and systems through learning from successes and failures: qualitative … Improving patient safety governance and systems through learning from successes and failures: qualitative … Perspectives on Safety Annual Perspective Impact of System Failures

185. Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia. | PSNet
     psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry
     September 28, 2017 - Study Patients' perspectives on quality and patient safety failures: lessons learned … Patients’ perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal … Patients’ perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal … September 28, 2017 Frequency and outcome of cervical cancer prevention failures in the

186. Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011. | PSNet
     psnet.ahrq.gov/issue/clinical-safety-englands-national-programme-it-retrospective-analysis-all-reported-safety
     December 31, 2014 - The researchers found that while most events were technical failures, incidents involving human errors … Technical failures affecting 10 or more patients accounted for nearly 25% of events and were more likely … May 10, 2013 Syndromic surveillance for health information system failures: a feasibility … November 2, 2010 A systematic review of failures in handoff communication during intrahospital

187. Formative evaluation of the video reflexive ethnography method, as applied to the physician–nurse dyad. | PSNet
     psnet.ahrq.gov/issue/formative-evaluation-video-reflexive-ethnography-method-applied-physician-nurse-dyad
     December 02, 2020 - December 19, 2018 Using incident reports to assess communication failures and patient … October 13, 2018 Identification and characterization of failures in infectious agent … View More Related Resources Using incident reports to assess communication failures … November 14, 2012 Communication failures in the operating room: an observational classification

188. Losing Laura. | PSNet
     psnet.ahrq.gov/issue/losing-laura
     June 06, 2018 - Written by the patient's husband, the article outlines the failures that led to her death despite the … Factors discussed include overreliance on poorly functioning technology, communication failures , … June 26, 2019 Inquiry into reporter's death finds multiple failures in care.

189. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39082/psn-pdf
     January 04, 2010 - /communication-practices-4-harvard-surgical-services-surgical-safety- collaborative Communication failures … Further research is required to determine if these findings represent pure communication failures, challenges … -harvard-surgical-services-surgical-safety-collaborative https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps … https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

190. Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis. | PSNet
     psnet.ahrq.gov/issue/prevalence-causes-and-severity-medication-administration-errors-neonatal-intensive-care-unit
     January 17, 2024 - The review highlights both active failures (e.g., similar drug packaging or names) and latent failures … Improving Diagnostic Safety and Quality April 26, 2023 Latent and active failures

191. Operating room to intensive care unit handoffs and the risks of patient harm. | PSNet
     psnet.ahrq.gov/issue/operating-room-intensive-care-unit-handoffs-and-risks-patient-harm
     October 05, 2022 - The authors identified 81 process failures and outlined recommendations to mitigate many of these risks … October 2, 2013 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

192. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845358/psn-pdf
     March 29, 2023 - research has documented implementation challenges and the potential for patient harm due to process failures … /psnet.ahrq.gov/issue/problem-medication-reconciliation https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors … https://psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events

193. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49581/psn-pdf
     March 21, 2009 - But a more robust analysis of a medication error allows reviewers to identify all the system failures … Latent Failures Latent failures are weaknesses in the structure of an organization and often include … Examples of such latent failures include the following: (i) lack of adequate drug information—no medication … Active Failures Active failures are errors committed by individuals, usually practitioners who are in … Active failures in this case included: (i) not viewing or checking the patient's complete medication

194. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33687/psn-pdf
     August 01, 2009 - More importantly, operational failures disrupt patient care, leading to uncompleted tasks and medical … Second, the lack of communication about failures keeps managers and relevant personnel unaware of the … Identification of systems failures in successful paediatric cardiac surgery. … The impact of operational failures on hospital nurses and their patients. … Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41:643-662.

195. The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned, | PSNet
     psnet.ahrq.gov/issue/postpartum-hemorrhage-patient-safety-bundle-implementation-single-institution-successes
     February 01, 2023 - The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures … The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures … The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures

196. Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care. | PSNet
     psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease-during-intensive
     June 22, 2022 - Study Medication reconciliation failures in children and young adults with chronic … 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

197. Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration. | PSNet
     psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment
     September 05, 2012 - Book/Report Work Design Drivers of Organizational Learning about Operational Failures … Citation Text: Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory … Citation Citation Text: Work Design Drivers of Organizational Learning about Operational Failures

198. Spotlight Case September 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
     September 01, 2003 - Evidence for Communication Failures Poor communication between team members accounted for 37% of all … errors in a 4-month period of observation in critical units Communication failures contributed to 16% … Evidence for Communication Failures (cont.) … reviewed over the past 4 years (Weinger, et al., unpublished work), Taxonomy of Communication Failures … in a safe environment Videotapes analyzed later to identify performance failures and structure interventions

199. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34784/psn-pdf
     June 24, 2015 - potential-improved-teamwork-reduce-medical-errors-emergency-department This article aims to introduce emergency department communities to teamwork systems, teamwork failures … that commonly occur, and the consequences of identified failures. … Discussion includes retrospective analysis of more than 50 incidents suggesting that nearly nine teamwork failures

200. 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