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Total Results: 8,190 records

Showing results for "failures".

181. 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

182. 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

183. Failure to Rescue
     psnet.ahrq.gov/taxonomy/term/3521/feed
     September 01, 2019 - Failure to Rescue Failure to Rescue

184. 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

185. 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.

186. Application of root cause analysis on malpractice claim files related to diagnostic failures. | PSNet
     psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic-failures
     March 01, 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. … Application of root cause analysis on malpractice claim files related to diagnostic failures.

187. 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

188. 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

189. 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

190. 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

191. 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

192. 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

193. 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

194. 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

195. 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

196. 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

197. Active Error (or Active Failure) | PSNet
     psnet.ahrq.gov/taxonomy/term/3451
     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

198. Patients' experiences of dental diagnostic failures: a qualitative study using social media. | PSNet
     psnet.ahrq.gov/issue/patients-experiences-dental-diagnostic-failures-qualitative-study-using-social-media
     September 06, 2017 - Study Patients' experiences of dental diagnostic failures: a qualitative study using … Patients' experiences of dental diagnostic failures: a qualitative study using social media. … Patients' experiences of dental diagnostic failures: a qualitative study using social media.

199. 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

200. Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. | PSNet
     psnet.ahrq.gov/issue/impact-interruptions-distractions-and-cognitive-load-procedure-failures-and-medication
     March 02, 2012 - Study Impact of interruptions, distractions, and cognitive load on procedure failures … Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration … Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration