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Showing results for "failures".

  1. Latent Error (or Latent Condition) | PSNet

    psnet.ahrq.gov/glossary/latent-error-or-latent-condition
    September 13, 2021 - Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed … Active failures, in contrast, are sometimes referred to as errors at the sharp end, or the personnel

  2. Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids. | PSNet

    psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report
    January 22, 2014 - Study Identifying systems failures in the pathway to a catastrophic event: an analysis … Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident … Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident

  3. Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions. | PSNet

    psnet.ahrq.gov/issue/delayed-recognition-deterioration-patients-general-wards-mostly-caused-human-related
    December 21, 2017 - recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures … Recognition of Deterioration of Patients in General Wards Is Mostly Caused by Human Related Monitoring Failures … Recognition of Deterioration of Patients in General Wards Is Mostly Caused by Human Related Monitoring Failures

  4. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. | PSNet

    psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient
    September 26, 2012 - Study Dropping the baton: a qualitative analysis of failures during the transition … Dropping the baton: a qualitative analysis of failures during the transition from emergency department … Dropping the baton: a qualitative analysis of failures during the transition from emergency department

  5. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
    July 01, 2007 - have negative effects on survival from cardiac arrest List the most common causes of defibrillator failures … Defibrillator failures: causes of problems and recommendations for improvement. … failures due to device-related issues Failure to properly maintain and check devices Batteries not … Defibrillator failures: causes of problems and recommendations for improvement. … Defibrillator failures: causes of problems and recommendations for improvement.

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867337/psn-pdf
    December 11, 2024 - perspectives-anesthesia-and-perioperative-patient-safety-past-present-and- future Achieving sustained improvements in patient safety requires learning from both safety failures … The Safety I framework includes using individual and system failures, analytics, culture, and technology

  7. Maternity Pre-arrival Instructions by 999 Call Handlers. | PSNet

    psnet.ahrq.gov/issue/maternity-pre-arrival-instructions-999-call-handlers
    February 16, 2022 - Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise … November 4, 2020 Clinical Investigation Booking Systems Failures: Written Communications

  8. How safety is compromised when hospital equipment is a poor fit for patients who are obese. | PSNet

    psnet.ahrq.gov/issue/how-safety-compromised-when-hospital-equipment-poor-fit-patients-who-are-obese
    October 07, 2020 - Download Citation Related Resources From the Same Author(s) Process failures … October 7, 2020 Patient harm resulting from medication reconciliation process failures … January 17, 2017 Preventing adverse events caused by emergency electrical power system failures

  9. Factors contributing to preventing operating room "never events": a machine learning analysis. | PSNet

    psnet.ahrq.gov/issue/factors-contributing-preventing-operating-room-never-events-machine-learning-analysis
    July 26, 2023 - From the Same Author(s) Using failure mode and effect analysis to identify potential failures … November 30, 2016 Operational failures detected by frontline acute care nurses. … June 27, 2018 Participating in a multisite study exploring operational failures encountered

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46570/psn-pdf
    April 12, 2019 - electronic-health-records https://psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision … https://psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844546/psn-pdf
    February 15, 2023 - gender-biases-and-diagnostic-delay-inflammatory-bowel-disease-multicenter- observational-study Women often experience misdiagnosis and diagnostic delays due to process failures … psnet.ahrq.gov/issue/unwell-women-misdiagnosis-and-myth-man-made-world https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis

  12. Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures. | PSNet

    psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care-failures
    April 24, 2018 - Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures … Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures. … Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures.

  13. Frequency and outcome of cervical cancer prevention failures in the United States. | PSNet

    psnet.ahrq.gov/issue/frequency-and-outcome-cervical-cancer-prevention-failures-united-states
    April 09, 2013 - Study Frequency and outcome of cervical cancer prevention failures in the United … Frequency and outcome of cervical cancer prevention failures in the United States. … Frequency and outcome of cervical cancer prevention failures in the United States.

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60277/psn-pdf
    January 01, 2021 - included inadequate communication among providers (55%), failure to respond (41%), and documentation failures … Both diagnosis-related and physiologic monitoring cases listing communication failures among providers

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841478/psn-pdf
    December 14, 2022 - The review highlights both active failures (e.g., similar drug packaging or names) and latent failures

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38881/psn-pdf
    November 08, 2012 - This column recounts a case of delayed diagnosis and examines how communication and process of care failures … issue/are-patients-part-blame-when-doctors-miss-diagnosis https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis

  17. Machine learning is booming in medicine. It’s also facing a credibility crisis. | PSNet

    psnet.ahrq.gov/issue/machine-learning-booming-medicine-its-also-facing-credibility-crisis
    May 22, 2019 - This news story highlights how underlying problems and testing failures limit the trustworthiness … December 1, 2021 Pathology Oversight Failures at the Veterans Health Care System of the

  18. Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. | PSNet

    psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs
    October 07, 2020 - This report summarizes an investigation of 25 imaging failures in the British National Health Service … October 5, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866111/psn-pdf
    June 12, 2024 - 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

  20. Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus. | PSNet

    psnet.ahrq.gov/issue/electronic-health-record-modernization-caused-pharmacy-related-patient-safety-issues
    January 31, 2024 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … January 24, 2024 Multiple Failures in Test Results Follow-up for a Patient Diagnosed … October 25, 2023 Failures in Care Coordination and Reviewing a Patient's Death at the
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