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Total Results: 8,190 records

Showing results for "failures".

  1. 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

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42875/psn-pdf
    January 22, 2014 - operating room identified six key concepts: indicators of effective communication, signs of communication failures … https://psnet.ahrq.gov/issue/communication-operating-theatre https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

  3. 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.

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41416/psn-pdf
    May 23, 2012 - emphasizes the importance of anesthesiologists performing pre-surgery safety checks to prevent equipment failures … association-anaesthetists-great-britain-and-ireland https://psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management-considerations-prevention

  5. 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

  6. Failure to Report | PSNet

    psnet.ahrq.gov/web-mm/failure-report
    July 01, 2008 - Because health care professionals often treat their mistakes as personal failures, I'd speculate that … debriefing of recently completed activities.( 10,11 ) Such discussions also foster a team awareness of failures

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43603/psn-pdf
    October 15, 2014 - psnet.ahrq.gov/issue/coaching-improve-quality-communication-during-briefings-and-debriefings Communication failures … coaching-improve-quality-communication-during-briefings-and-debriefings https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

  8. 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

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845277/psn-pdf
    March 01, 2023 - effects, and criticality analysis (FMECA) to create an acute stroke diagnostic process map, identify failures … The FMECA process identified several steps in the diagnostic process as the most critical failures to

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45160/psn-pdf
    May 18, 2016 - primary-care-closed-claims-experience-massachusetts-malpractice-insurers https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures … -2015-annual-benchmarking-report https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44889/psn-pdf
    April 13, 2017 - /organizational-learning-framework-patient-safety Organizations are encouraged to learn from their failures … This commentary presents a model to help organizations learn from system failures through focusing on

  12. Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. | PSNet

    psnet.ahrq.gov/issue/deficiencies-emergent-and-outpatient-care-patient-alcohol-use-disorder-richard-l-roudebush-va
    July 13, 2022 - Copy Citation Related Resources From the Same Author(s) Multiple Failures … July 26, 2023 Failures in Care Coordination and Reviewing a Patient's Death at the VA … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

  13. Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives. | PSNet

    psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients-primary-care-uk
    November 20, 2015 - Study Routine failures in the process for blood testing and the communication of … Routine failures in the process for blood testing and the communication of results to patients in primary … Routine failures in the process for blood testing and the communication of results to patients in primary

  14. 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

  15. 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

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34721/psn-pdf
    November 19, 2015 - The most common types of preventable events are technical errors, errors in diagnosis, failures of prevention … Diagnostic mishaps and late surgical failures had the highest rates of preventability.

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45188/psn-pdf
    June 01, 2016 - This newsletter article discusses how workarounds serve as indicators of system failures and present … reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-term-remedies https://psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38544/psn-pdf
    September 02, 2009 - A prior study found that communication failures were a contributing factor to errors in this situation … pilot-study-examining-undesirable-events-among-emergency-department-boarded-patients-awaiting https://psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40690/psn-pdf
    August 17, 2011 - designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure- mode-and-effect A prospective failure mode and effect analysis identified 57 potential failures … Most of these potential failures require technological rather than educational or policy-based solutions

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34775/psn-pdf
    February 07, 2019 - attendees, Berwick uses the story of the Mann Gulch Fire tragedy  to frame a series of reflections on the failures … He builds on the anecdotes by describing factors that contribute to an organization’s failures, once
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