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Total Results: 7,834 records

Showing results for "failures".

301. Preventable closed claims in the AANA Foundation closed malpractice claims database. | PSNet
     psnet.ahrq.gov/issue/preventable-closed-claims-aana-foundation-closed-malpractice-claims-database
     March 11, 2020 - Among the factors identified as being associated with preventable events were communication failures … Improper Medication Labeling in an Operating Room April 27, 2022 Communication failures

302. 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.

303. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47193/psn-pdf
     September 05, 2018 - , Recommendation (SBAR) is a mnemonic used to structure information sharing to avoid communication failures … implementing-sbar-across-large-multihospital-health-system https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

304. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47418/psn-pdf
     September 19, 2018 - /issue/how-communications-issues-between-doctors-and-nurses-can-affect-your- health Communication failures … how-communications-issues-between-doctors-and-nurses-can-affect-your-health https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

305. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45021/psn-pdf
     April 06, 2016 - scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs Latent factors are known to contribute to system-level failures … meet performance targets and insufficient safety culture led to unintended consequences and system failures

306. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43550/psn-pdf
     October 15, 2014 - medical records (EMRs), they will need contingency plans to ensure patient safety in the event of system failures … survey of 50 institutions with fully integrated EMRs found that nearly all had experienced unexpected failures

307. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34667/psn-pdf
     January 17, 2018 - authors (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

308. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39975/psn-pdf
     March 03, 2011 - https://psnet.ahrq.gov/issue/communication-failure-operating-room Communication failures are a well-characterized … this study, implementation of a teamwork training program was associated with fewer communication failures

309. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45438/psn-pdf
     September 07, 2016 - 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

310. Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition. | PSNet
     psnet.ahrq.gov/issue/durasal-durezol-mix-illustrates-how-dangerous-product-problems-persist-long-after-recognition
     June 10, 2018 - This newsletter article reveals system failures that contribute to continued drug name confusion , even … June 10, 2018 Multiple latent failures align to allow a serious drug interaction to harm

311. Medical Liability: New Ideals for Making the System Work Better for Patients. | PSNet
     psnet.ahrq.gov/issue/medical-liability-new-ideals-making-system-work-better-patients
     May 18, 2011 - liability system to more effectively help patients, families, and physicians who have been affected by failures … More Related Resources A System in Need of Repair: Addressing Organizational Failures

312. How communications issues between doctors and nurses can affect your health. | PSNet
     psnet.ahrq.gov/issue/how-communications-issues-between-doctors-and-nurses-can-affect-your-health
     September 28, 2016 - Communication failures in health care routinely challenge patient safety. … January 20, 2020 Using incident reports to assess communication failures and patient

313. Is health care getting safer? | PSNet
     psnet.ahrq.gov/issue/health-care-getting-safer
     December 14, 2016 - February 8, 2017 Identifying systems failures in the pathway to a catastrophic event: … March 4, 2011 Surgical technology and operating-room safety failures: a systematic review … August 13, 2013 An observational study of the frequency, severity, and etiology of failures

314. Engineering the system of communication for safer surgery. | PSNet
     psnet.ahrq.gov/issue/engineering-system-communication-safer-surgery
     January 18, 2013 - the Same Author(s) An observational study of the frequency, severity, and etiology of failures … August 11, 2010 Failures in communication and information transfer across the surgical … September 9, 2011 Surgical technology and operating-room safety failures: a systematic

315. Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities. | PSNet
     psnet.ahrq.gov/issue/evaluation-registered-nurse-competency-processes-veterans-health-administration-facilities
     April 26, 2006 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … September 5, 2012 Identifying the latent failures underpinning medication administration

316. Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes. | PSNet
     psnet.ahrq.gov/issue/improving-medication-administration-safety-using-naive-observation-assess-practice-and-guide
     October 06, 2016 - April 24, 2018 Operational failures detected by frontline acute care nurses. … One Bronchoscopy, Two Errors January 1, 2019 Inattentional blindness and failures … recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures

317. A multicenter collaborative approach to reducing pediatric codes outside the ICU. | PSNet
     psnet.ahrq.gov/issue/multicenter-collaborative-approach-reducing-pediatric-codes-outside-icu
     August 13, 2014 - Related Resources From the Same Author(s) Decreasing handoff-related care failures … July 19, 2023 Operational failures detected by frontline acute care nurses. … Improving Diagnostic Safety and Quality April 26, 2023 Using trainee failures

318. Systems approaches to surgical quality and safety: from concept to measurement. | PSNet
     psnet.ahrq.gov/issue/systems-approaches-surgical-quality-and-safety-concept-measurement
     January 19, 2016 - October 20, 2014 Surgical technology and operating-room safety failures: a systematic … March 3, 2011 An observational study of the frequency, severity, and etiology of failures … August 15, 2013 Surgical technology and operating-room safety failures: a systematic

319. 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

320. 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