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Showing results for "failures".

221. 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.

222. 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

223. Implement strategies to prevent persistent medication errors and hazards: 2024. | PSNet
     psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024
     April 17, 2024 - Systemic failures can perpetuate unsafe care if a lack of prioritization distracts from efforts to … April 5, 2023 Latent and active failures perfectly align to allow a preventable adverse

224. 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

225. 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

226. Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios. | PSNet
     psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care-emergency-and
     October 12, 2016 - Study Inattentional blindness and failures to rescue the deteriorating patient in … Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency … Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency

227. 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

228. 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

229. Information transfer and communication in surgery: a systematic review. | PSNet
     psnet.ahrq.gov/issue/information-transfer-and-communication-surgery-systematic-review
     September 26, 2012 - This systematic review of 38 published studies identified communication failures in all phases of surgical … RIS Download Citation Related Resources From the Same Author(s) Failures … February 9, 2011 An observational study of the frequency, severity, and etiology of failures

230. Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique. | PSNet
     psnet.ahrq.gov/issue/teaching-nursing-students-ethical-and-legal-consequences-medical-errors-insights-radonda
     July 05, 2017 - students reported greater understanding of error reporting, the role of state boards of nursing, system failures … Download Citation Related Resources From the Same Author(s) Operational failures … April 17, 2024 Systemic failures in health care oversight.

231. Silence, power and communication in the operating room. | PSNet
     psnet.ahrq.gov/issue/silence-power-and-communication-operating-room
     June 08, 2011 - Communication failures are a known problem in operating rooms, with past studies examining the role … Interprofessional conflict can be a mediating factor in such failures, and this ethnographic study … August 10, 2011 Communication failures in the operating room: an observational classification

232. Technology, Education and Safety. | PSNet
     psnet.ahrq.gov/issue/technology-education-and-safety
     December 15, 2021 - They include automation failures , the role of the obstetric anesthesiologist in maternal safety , … March 27, 2024 Automation failures and patient safety.

233. Swiss Cheese Model | PSNet
     psnet.ahrq.gov/taxonomy/term/3460
     August 11, 2025 - 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.

234. 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

235. 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

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. What do patients and relatives know about problems and failures in care? | PSNet
     psnet.ahrq.gov/issue/what-do-patients-and-relatives-know-about-problems-and-failures-care
     November 28, 2016 - Study What do patients and relatives know about problems and failures in care? … What do patients and relatives know about problems and failures in care? … What do patients and relatives know about problems and failures in care?

238. Communication failures in the operating room: an observational classification of recurrent types and effects. | PSNet
     psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and
     April 06, 2011 - Study Classic Communication failures in the operating room … Communication failures in the operating room: an observational classification of recurrent types and … Communication failures in the operating room: an observational classification of recurrent types and

239. Temporarily holding medication orders safely in order to prevent patient harm. | PSNet
     psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
     March 14, 2023 - , 2023 Patient death tied to lack of proper escalation process for barcode scanning failures … October 4, 2023 Latent and active failures perfectly align to allow a preventable adverse … April 5, 2023 Latent and active failures perfectly align to allow a preventable adverse

240. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47596/psn-pdf
     March 27, 2019 - Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures