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Showing results for "failures".

221. 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

222. 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

223. 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

224. 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

225. 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

226. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852278/psn-pdf
     August 09, 2023 - study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures … Four categories of failures were identified: technical issues, patient safety, communication, and social

227. 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

228. 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

229. 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

230. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73639/psn-pdf
     August 25, 2021 -   https://psnet.ahrq.gov/issue/safety-maternity-services-england High-profile failures motivate … This report builds on maternity care failures in National Health Service trusts to recommend needed

231. Postoperative handover: problems, pitfalls, and prevention of error. | PSNet
     psnet.ahrq.gov/issue/postoperative-handover-problems-pitfalls-and-prevention-error
     September 26, 2012 - RIS Download Citation Related Resources From the Same Author(s) Failures … July 6, 2012 An observational study of the frequency, severity, and etiology of failures … February 23, 2011 Surgical technology and operating-room safety failures: a systematic … October 27, 2022 An observational study of postoperative handoff standardization failures

232. Overreaction. | PSNet
     psnet.ahrq.gov/issue/overreaction
     November 15, 2023 - August 28, 2019 Operational failures detected by frontline acute care nurses. … Hemolysis Holdup May 1, 2017 Weak oversight allows lab failures … October 8, 2013 Inquiry into reporter's death finds multiple failures in care.

233. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74212/psn-pdf
     January 01, 2022 - Using failure mode and effects analysis (FMEA), researchers identified potential failures related to … Common failures included incorrect patient information, non-standardized chemotherapy protocols, and

234. 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

235. 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.

236. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/861292/psn-pdf
     January 24, 2024 - 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

237. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60648/psn-pdf
     July 01, 2020 - //psnet.ahrq.gov/issue/chronicle-pandemic-foretold-learning-covid-19-failure-next-outbreak-arrives Failures … failure-next-outbreak-arrives https://psnet.ahrq.gov/issue/dennis-quaids-quest https://psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report

238. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74005/psn-pdf
     October 27, 2021 - 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

239. Swiss Cheese Model | PSNet
     psnet.ahrq.gov/glossary/swiss-cheese-model
     September 13, 2021 - developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures … tend to reveal multiple, smaller failures leading up to the actual hazard.

240. Pump up the volume: how to prioritize events and analyze error data. | PSNet
     psnet.ahrq.gov/issue/pump-volume-how-prioritize-events-and-analyze-error-data
     March 14, 2023 - March 3, 2021 Latent and active failures perfectly align to allow a preventable adverse … , 2023 Patient death tied to lack of proper escalation process for barcode scanning failures … February 8, 2023 Latent and active failures perfectly align to allow a preventable adverse