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Total Results: 7,834 records

Showing results for "failures".

201. Patient reports of preventable problems and harms in primary health care. | PSNet
     psnet.ahrq.gov/issue/patient-reports-preventable-problems-and-harms-primary-health-care
     February 03, 2011 - breakdowns in the clinician–patient relationship as medical errors than adverse drug events or technical failures … January 18, 2013 Effect of reducing interns' weekly work hours on sleep and attentional failures … May 20, 2020 Failures in the respectful care of critically ill patients.

202. The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. | PSNet
     psnet.ahrq.gov/issue/silent-treatment-why-safety-tools-and-checklists-arent-enough-save-lives
     April 03, 2009 - Silence Kills was a 2005 report that highlighted communication failures that contribute to patient … existing safety tools, such as checklists , are not in themselves solutions to these communication failures … June 10, 2018 Work Design Drivers of Organizational Learning about Operational Failures

203. Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study. | PSNet
     psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits-middle-aged-and-older
     November 15, 2023 - Study Information management goals and process failures during home visits for middle-aged … Information management goals and process failures during home visits for middle-aged and older adults … Information management goals and process failures during home visits for middle-aged and older adults

204. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34735/psn-pdf
     June 16, 2014 - Organisation with a Memory set out to understand what was known about the scale and nature of serious failures … United Kingdom’s National Health Service (NHS) system, examine how the NHS might learn from those failures … , and recommend methods to minimize future failures.

205. Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures? A retrospective study of electronic health record data. | PSNet
     psnet.ahrq.gov/issue/does-nurse-use-standardized-flowsheet-document-communication-advanced-providers-provide
     June 22, 2022 - flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures … flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures … flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures

206. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37498/psn-pdf
     April 30, 2014 - preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures … a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures … and Structured communication tools are being used increasingly to prevent critical communication failures

207. The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness. | PSNet
     psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors-system-failures
     February 23, 2018 - The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures … Text: The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures … Text: The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures

208. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72536/psn-pdf
     December 02, 2020 - They include automation failures, the role of the obstetric anesthesiologist in maternal safety, and … https://psnet.ahrq.gov/issue/patient-safety-anesthetic-practice https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety

209. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867747/psn-pdf
     March 12, 2025 - issue/framework-analysis-communication-errors-health-care https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims … https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report

210. The practice of respect in the ICU. | PSNet
     psnet.ahrq.gov/issue/practice-respect-icu
     August 09, 2018 - the need to expand the research on respect in the intensive care unit and the value of responding to failures … October 19, 2022 Failures in the respectful care of critically ill patients. … April 13, 2022 Failures in the respectful care of critically ill patients.

211. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73454/psn-pdf
     June 30, 2021 - https://psnet.ahrq.gov/issue/poor-physician-patient-communication-and-medical-error Communication failures … issue/poor-physician-patient-communication-and-medical-error https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

212. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40453/psn-pdf
     May 18, 2011 - This article discusses a patient who experienced delays in care due to a myriad of system failures in … The invited discussant explores the causes of these failures and discusses situational awareness, improved … The fact that JAMA chose a clinical scenario focusing on systems failures mirrors past efforts in the

213. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38712/psn-pdf
     June 17, 2009 - https://psnet.ahrq.gov/issue/silence-power-and-communication-operating-room Communication failures are … Interprofessional conflict can be a mediating factor in such failures, and this ethnographic study aimed … psnet.ahrq.gov/issue/silence-power-and-communication-operating-room https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

214. 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

215. 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.

216. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865594/psn-pdf
     January 01, 2025 - understanding-informal-aspects-medication-processes-maintain-patient-safety- hospitals Medication errors are often the result of both individual failures … psnet.ahrq.gov/primer/medication-administration-errors https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers

217. Double Dosing, by the Rules | PSNet
     psnet.ahrq.gov/web-mm/double-dosing-rules
     February 03, 2010 - But a more robust analysis of a medication error allows reviewers to identify all the system failures … developing system strategies to reduce or eliminate medication errors.( 2 ) Both latent and active failures … Latent Failures Latent failures are weaknesses in the structure of an organization and often include … Active Failures Active failures are errors committed by individuals, usually practitioners who are … Active failures in this case included: (i) not viewing or checking the patient's complete medication

218. 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.

219. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42900/psn-pdf
     September 19, 2016 - The case reviews revealed communication failures, such as lack of discussion about suicide risks or … sentinel-event-alert https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps … https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps https://psnet.ahrq.gov

220. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38076/psn-pdf
     February 15, 2011 - consequences-inadequate-sign-out-patient-care With reductions in resident work hours, a greater number of communication failures … The authors also reported that failures to provide an accurate overall picture of the patient led to … common-program-requirements-learning-and-working-environment-duty-hours https://psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident