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Total Results: 7,834 records

Showing results for "failures".

261. 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

262. 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

263. Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery. | PSNet
     psnet.ahrq.gov/issue/computer-assisted-process-modeling-enhance-intraoperative-safety-cardiac-surgery
     July 19, 2023 - 12, 2009 View More Related Resources Giving up learning from failures … An examination of learning from one's own failures in the context of heart surgeons. … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures

264. 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

265. Identifying failure modes in telemedicine: an instructional needs assessment. | PSNet
     psnet.ahrq.gov/issue/identifying-failure-modes-telemedicine-instructional-needs-assessment
     August 23, 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

266. 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

267. 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

268. Patient Safety: A Case-based Innovative Playbook for Safer Care. Second Edition. | PSNet
     psnet.ahrq.gov/issue/patient-safety-case-based-innovative-playbook-safer-care-second-edition
     September 11, 2019 - emerged in prominence due to the COVID-19 pandemic (health disparities, inequities and nursing home care failures … August 28, 2019 Mistakes, Errors and Failures across Cultures.

269. Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. | PSNet
     psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals
     June 16, 2019 - (experts from the Institute for Safe Medication Practices) discovered more than 50 latent system failures … The authors discuss the need to look beyond individuals and focus on the multiple system failures that

270. A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays. | PSNet
     psnet.ahrq.gov/issue/25-year-old-teacher-died-after-waiting-hours-er-shes-not-only-one-who-saw-delays
     September 09, 2020 - Delays in emergency room (ER) triage and assessment contribute to wide range of failures that degrade … September 9, 2020 Weak oversight allows lab failures to put patients at risk.

271. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47477/psn-pdf
     November 14, 2018 - Written by the patient's husband, the article outlines the failures that led to her death despite the … Factors discussed include overreliance on poorly functioning technology, communication failures, and

272. 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

273. Intubation Mishap | PSNet
     psnet.ahrq.gov/web-mm/intubation-mishap
     April 26, 2023 - Coordination is dependent on effective communication.( 4 ) The Evidence for Communication Failures … At Dartmouth-Hitchcock Medical Center, failures of team communication were identified in 61% of the 42 … Taxonomy of Communication Failures . … —There are many types of communication failures and many ways to classify them. … Fundamentally, they can be broken down into failures of message transmission and reception.

274. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836812/psn-pdf
     March 30, 2022 - analysis (FMEA) is a structured adverse event analysis tool that aims to prospectively identify potential failures … The goal of FMEA is to prioritize failures based on their potential seriousness and to design and implement … actions to mitigate or prevent failures in order of priority. … The term “effects analysis” refers to analyzing the consequences of such failures by prioritizing their … improving-process-while-changing-practice-fmea-and-medication-administration https://psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method

275. 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

276. 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

277. The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. | PSNet
     psnet.ahrq.gov/issue/differences-between-human-error-risk-behavior-and-reckless-behavior-are-key-just-culture
     September 23, 2020 - different types of flawed human behavior and designing effective organizational responses to these failures … March 27, 2024 Latent and active failures perfectly align to allow a preventable adverse

278. Allowing failure for educational purposes in postgraduate clinical training: a narrative review. | PSNet
     psnet.ahrq.gov/issue/allowing-failure-educational-purposes-postgraduate-clinical-training-narrative-review
     February 08, 2023 - This review examined the use of learning from failures in postgraduate medicine and found further research … Download Citation Related Resources From the Same Author(s) Using trainee failures

279. Critical Deficiencies at the Washington DC VA Medical Center. | PSNet
     psnet.ahrq.gov/issue/critical-deficiencies-washington-dc-va-medical-center
     December 16, 2020 - Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures . … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

280. The rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient safety. | PSNet
     psnet.ahrq.gov/issue/rising-frequency-it-blackouts-indicates-increasing-relevance-it-emergency-concepts-ensure
     October 12, 2022 - This review discusses ways to protect against large-scale failures of health IT systems and categorizes … the types of failures that can occur.