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Showing results for "failures".

21. Communication failures contributing to patient injury in anaesthesia malpractice claims. | PSNet
    psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims
    August 04, 2021 - Study Communication failures contributing to patient injury in anaesthesia malpractice … Communication failures contributing to patient injury in anaesthesia malpractice claims. … malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures … Communication failures contributing to patient injury in anaesthesia malpractice claims.

22. Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures. | PSNet
    psnet.ahrq.gov/issue/deficiencies-community-care-network-credentialing-process-former-va-surgeon-and-veterans
    November 29, 2023 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … network weakened by interorganizational communication gaps, data inconsistencies, and information failures … April 26, 2006 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … October 25, 2023 A System in Need of Repair: Addressing Organizational Failures of the

23. Operational failures in general practice: a consensus-building study on the priorities for improvement. | PSNet
    psnet.ahrq.gov/issue/operational-failures-general-practice-consensus-building-study-priorities-improvement
    February 07, 2024 - Study Operational failures in general practice: a consensus-building study on the … Operational failures in general practice: a consensus-building study on the priorities for improvement … Operational failures (e.g., distractions, situational constraints) can impact the delivery of safe, … Operational failures in general practice: a consensus-building study on the priorities for improvement … February 7, 2024 Impacts of operational failures on primary care physicians' work: a

24. Process failures that increase the risk of infection through respiratory droplets: a study of patient safety events reported by hospitals across Pennsylvania. | PSNet
    psnet.ahrq.gov/issue/process-failures-increase-risk-infection-through-respiratory-droplets-study-patient-safety
    March 24, 2021 - Study Process failures that increase the risk of infection through respiratory droplets … Process failures that increase the risk of infection through respiratory droplets: a study of patient … In an effort to identify process failures related to infectious disease spread in hospital settings … The analysis identified several process failures, most commonly involving the testing or processing of … The authors also discuss risk-reduction strategies to reduce the process failures contributing to the

25. Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction. | PSNet
    psnet.ahrq.gov/issue/work-environment-and-operational-failures-associated-nurse-outcomes-patient-safety-and
    March 17, 2021 - Study Work environment and operational failures associated with nurse outcomes, patient … Work environment and operational failures associated with nurse outcomes, patient safety, and patient … Operational failures – breakdowns in care processes, such as distractions or situational constraints … Findings indicate that operational failures negatively impact patient satisfaction, quality and safety … Work environment and operational failures associated with nurse outcomes, patient safety, and patient

26. Patient death tied to lack of proper escalation process for barcode scanning failures. | PSNet
    psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures
    November 01, 2023 - Article Patient death tied to lack of proper escalation process for barcode scanning failures … Citation Text: Patient death tied to lack of proper escalation process for barcode scanning failures … solution availability and staffing improvements are discussed to minimize opportunities for the systemic failures … Citation Citation Text: Patient death tied to lack of proper escalation process for barcode scanning failures … March 14, 2023 Latent and active failures perfectly align to allow a preventable adverse

27. Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. | PSNet
    psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report
    July 18, 2018 - Book/Report Malpractice Risks in Communication Failures: 2015 Annual Benchmarking … Citation Text: Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … Communication failures are known to contribute to medical errors. … communication breakdowns led to patient harm, this report explores selected specialties where such failures … Cite Citation Citation Text: Malpractice Risks in Communication Failures

28. Systemic failures in nursing home care--a scoping study. | PSNet
    psnet.ahrq.gov/issue/systemic-failures-nursing-home-care-scoping-study
    July 17, 2013 - Review Systemic failures in nursing home care--a scoping study. … Systemic failures in nursing home care—A scoping study. … Systemic failures in nursing home care—A scoping study.

29. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866080/psn-pdf
    June 05, 2024 - Giving up learning from failures? … Giving up learning from failures? … https://psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart … https://psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons … https://psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons

30. Preventing blood transfusion failures: FMEA, an effective assessment method. | PSNet
    psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method
    August 25, 2021 - Study Preventing blood transfusion failures: FMEA, an effective assessment method … Preventing blood transfusion failures: FMEA, an effective assessment method. … Preventing blood transfusion failures: FMEA, an effective assessment method.

31. Using incident reports to assess communication failures and patient outcomes. | PSNet
    psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes
    February 06, 2019 - Study Using incident reports to assess communication failures and patient outcomes … Using Incident Reports to Assess Communication Failures and Patient Outcomes. … Communication failures are a common underlying factor in adverse events. … Although the relationship between communication failures and safety has been best studied in the operating … Using Incident Reports to Assess Communication Failures and Patient Outcomes.

32. A systematic review of failures in handoff communication during intrahospital transfers. | PSNet
    psnet.ahrq.gov/issue/systematic-review-failures-handoff-communication-during-intrahospital-transfers
    November 03, 2015 - Review A systematic review of failures in handoff communication during intrahospital … A systematic review of failures in handoff communication during intrahospital transfers. … Communication failures at the time of patient handoffs have been frequently implicated in adverse … A systematic review of failures in handoff communication during intrahospital transfers. … November 3, 2015 Syndromic surveillance for health information system failures: a feasibility

33. Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study. | PSNet
    psnet.ahrq.gov/issue/identification-and-characterization-failures-infectious-agent-transmission-precaution
    October 13, 2018 - Emerging Classic Identification and characterization of failures … Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices … This direct observation study observed frequent failures in use of PPE, including entering rooms without … The authors suggest that given the wide range of failures, a variety of strategies are needed to improve … Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices

34. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/865930/psn-pdf
    May 22, 2024 - Operational failures in general practice: a consensus- building study on the priorities for improvement … Operational failures in general practice: a consensus-building study on the priorities for improvement … https://psnet.ahrq.gov/issue/operational-failures-general-practice-consensus-building-study-priorities … - improvement Operational failures (e.g., distractions, situational constraints) can impact the delivery … in the UK National Health Service (NHS), used a modified Delphi process to prioritize operational failures

35. Classification of failures in the perception of conversational agents (CAs) and their implications on patient safety. | PSNet
    psnet.ahrq.gov/issue/classification-failures-perception-conversational-agents-cas-and-their-implications-patient
    July 06, 2022 - Study Classification of failures in the perception of conversational agents (CAs) … Classification of failures in the perception of conversational agents (CAs) and their implications on … Investigators used these CAs to detect errors and failures in calculating correct insulin doses. … Potential failures must be considered before deployment of CAs in safety-critical environments. … Classification of failures in the perception of conversational agents (CAs) and their implications on

36. Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia. | PSNet
    psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical
    July 26, 2023 - Book/Report Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … Citation Text: Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer … Cancer test communication failures can contribute to physical, emotional, and financial patient harm. … Copy URL Cite Citation Citation Text: Multiple Failures … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

37. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/843086/psn-pdf
    January 25, 2023 - Work environment and operational failures associated with nurse outcomes, patient safety, and patient … Work environment and operational failures associated with nurse outcomes, patient safety, and patient … Operational failures – breakdowns in care processes, such as distractions or situational constraints … using population-based survey data from 11,709 nurses examined the relationship between operational failures … Findings indicate that operational failures negatively impact patient satisfaction, quality and safety

38. An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery. | PSNet
    psnet.ahrq.gov/issue/observational-study-frequency-severity-and-etiology-failures-postoperative-care-after-major
    August 11, 2010 - Study An observational study of the frequency, severity, and etiology of failures … An observational study of the frequency, severity, and etiology of failures in postoperative care after … This observational study at a large teaching hospital found that process failures in postoperative … An observational study of the frequency, severity, and etiology of failures in postoperative care after … August 11, 2010 Failures in communication and information transfer across the surgical

39. Multiple latent failures align to allow a serious drug interaction to harm a patient. | PSNet
    psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient
    June 10, 2018 - Newspaper/Magazine Article Multiple latent failures align to allow a serious drug … Citation Text: Multiple latent failures align to allow a serious drug interaction to harm a patient … Detailing a case in which latent failures  led to patient harm, this article encourages health care … providers investigating adverse events to consider how both active and latent failures may line up … Copy URL Cite Citation Citation Text: Multiple latent failures

40. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60325/psn-pdf
    May 13, 2020 - Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis … Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis … https://psnet.ahrq.gov/issue/impacts-operational-failures-primary-care-physicians-work-critical-interpretive … - synthesis This review synthesized research exploring how operational failures (e.g., distractions … The authors suggest that future research focus on which operational failures have the highest impact