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Total Results: 8,190 records

Showing results for "failures".

301. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44577/psn-pdf
     October 21, 2015 - improving-patient-safety-clinical-oncology-applying-lessons-normal-accident- theory The Normal Accident Theory suggests that failures … are inevitable in complex environments, but proactive analysis of potential failures within systems

302. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46024/psn-pdf
     June 15, 2017 - issue/introductions-during-time-outs-do-surgical-team-members-know-one-anothers- names Communication failures … introductions-during-time-outs-do-surgical-team-members-know-one-anothers-names https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

303. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43040/psn-pdf
     March 05, 2014 - derived from James Reason’s model of organizational accidents, which differentiates active from latent failures … psnet.ahrq.gov/issue/managing-risks-organizational-accidents https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

304. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45493/psn-pdf
     December 07, 2016 - This review discusses ways to protect against large-scale failures of health IT systems and categorizes … the types of failures that can occur.

305. Decimal numbers and safe interpretation of clinical pathology results. | PSNet
     psnet.ahrq.gov/issue/decimal-numbers-and-safe-interpretation-clinical-pathology-results
     July 16, 2014 - January 12, 2011 Operational failures in general practice: a consensus-building study … May 22, 2024 Impacts of operational failures on primary care physicians' work: a critical … November 16, 2022 Operational failures detected by frontline acute care nurses.

306. 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

307. 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

308. Harveian Oration 2018: improving quality and safety in healthcare. | PSNet
     psnet.ahrq.gov/issue/harveian-oration-2018-improving-quality-and-safety-healthcare
     January 23, 2019 - The United Kingdom National Health Service (NHS) is known for both patient safety achievements and failures … August 31, 2022 Operational failures in general practice: a consensus-building study

309. 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.

310. 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

311. 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

312. 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.

313. 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

314. 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

315. 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

316. 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

317. An organizational learning framework for patient safety. | PSNet
     psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
     November 28, 2018 - Organizations are encouraged to learn from their failures, but evidence shows that changes after … This commentary presents a model to help organizations learn from system failures through focusing

318. 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

319. 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

320. 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.