Results

Total Results: 7,834 records

Showing results for "failures".

281. Unstoppable: this doctor has been investigated at every level of government. How is he still practicing? | PSNet
     psnet.ahrq.gov/issue/unstoppable-doctor-has-been-investigated-every-level-government-how-he-still-practicing
     September 16, 2020 - Systemic failures can enable poor practice to perpetuate without regard to safety. … More Related Resources Patients' perspectives on quality and patient safety failures

282. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. | PSNet
     psnet.ahrq.gov/issue/perfect-storm-averted-flawed-systems-dropped-ball-and-cognitive-biases-delay-critical
     November 30, 2022 - disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures … September 8, 2021 Preventing and mitigating radiology system failures: a guide to disaster

283. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. | PSNet
     psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
     April 27, 2019 - A prospective failure mode and effect analysis identified 57 potential failures that each could lead … Most of these potential failures require technological rather than educational or policy-based solutions

284. A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. | PSNet
     psnet.ahrq.gov/issue/pilot-study-examining-undesirable-events-among-emergency-department-boarded-patients-awaiting
     August 04, 2021 - A prior study found that communication failures were a contributing factor to errors in this situation … October 15, 2014 Inquiry into reporter's death finds multiple failures in care.

285. Semantically ambiguous language in the teaching operating room. | PSNet
     psnet.ahrq.gov/issue/semantically-ambiguous-language-teaching-operating-room
     November 11, 2020 - Communication failures are a common cause of patient harm. … November 17, 2021 Communication failures contributing to patient injury in anaesthesia

286. Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. | PSNet
     psnet.ahrq.gov/issue/effects-interdisciplinary-collaboration-hospitals-medication-errors-integrative-review
     June 16, 2021 - Communication failures hinder safety of health care delivery and are particularly prevalent in medication … September 6, 2017 Failures in communication through documents and documentation across

287. Scandal as a sentinel event—recognizing hidden cost–quality trade-offs. | PSNet
     psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs
     November 04, 2020 - Latent factors are known to contribute to system-level failures. … meet performance targets and insufficient safety culture led to unintended consequences and system failures

288. 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database. | PSNet
     psnet.ahrq.gov/issue/2020-pennsylvania-patient-safety-reporting-analysis-serious-events-and-incidents-nations
     July 06, 2022 - July 13, 2022 Patient harm resulting from medication reconciliation process failures: … June 29, 2022 Process failures that increase the risk of infection through respiratory … January 19, 2022 Communication failures contributing to patient injury in anaesthesia

289. Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020. | PSNet
     psnet.ahrq.gov/issue/comprehensive-healthcare-inspection-summary-report-evaluation-mental-health-veterans-health
     July 13, 2022 - Copy Citation Related Resources From the Same Author(s) Multiple Failures … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … April 19, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

290. Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals. | PSNet
     psnet.ahrq.gov/issue/safety-events-impacting-hospitalized-patients-following-motor-vehicle-crashes-qualitative
     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 … 2020 Health literacy-related safety events: a qualitative study of health literacy failures

291. 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

292. 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.

293. 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

294. 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

295. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47064/psn-pdf
     August 22, 2018 - psnet.ahrq.gov/issue/lax-oversight-leaves-surgery-center-regulators-and-patients-dark High-profile failures … Enhanced transparency regarding those failures can enable informed patient decision-making when choosing

296. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33589/psn-pdf
     September 15, 2024 - operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures … complexity of operations and the risk of significant and even potentially catastrophic consequences when failures … thinking: preoccupation with failure; reluctance to simplify explanations for operations, successes, and failures … resilience is rooted in the fundamental understanding of the frequently unpredictable nature of system failures

297. Building patient safety skills: common pitfalls when conducting a root cause analysis. | PSNet
     psnet.ahrq.gov/issue/building-patient-safety-skills-common-pitfalls-when-conducting-root-cause-analysis
     May 07, 2018 - This piece highlights common failures in root cause analysis  (RCA) and explains how each undermines … June 27, 2018 Multiple latent failures align to allow a serious drug interaction to harm

298. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45815/psn-pdf
     January 25, 2017 - Improvement efforts have focused on care transitions, which are known to be vulnerable to communication failures … psnet.ahrq.gov/primer/handoffs-and-signouts https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-failures-childrens-hospitals

299. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39064/psn-pdf
     October 28, 2009 - Use of failure mode and effects analysis for proactive identification of communication and handoff failures … Use of failure mode and effects analysis for proactive identification of communication and handoff failures

300. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47252/psn-pdf
     August 01, 2018 - https://psnet.ahrq.gov/issue/communication-errors-radiology-pitfalls-and-how-avoid-them Communication failures … communication-errors-radiology-pitfalls-and-how-avoid-them https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps