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Total Results: 8,190 records

Showing results for "failures".

321. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40355/psn-pdf
     July 09, 2012 - silent-treatment-why-safety-tools-and-checklists-arent-enough-save-lives Silence Kills was a 2005 report that highlighted communication failures … existing safety tools, such as checklists, are not in themselves solutions to these communication failures

322. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37378/psn-pdf
     February 24, 2011 - medication-discrepancies-resident-sign-outs-and-their-potential-harm Efforts to standardize hand-offs remain a critical part of preventing communication failures … psnet.ahrq.gov/issue/model-building-standardized-hand-protocol https://psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident

323. 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

324. 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

325. 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

326. 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

327. 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

328. 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

329. 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

330. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39753/psn-pdf
     September 28, 2016 - psnet.ahrq.gov/issue/nursing-care-quality-and-adverse-events-us-hospitals Interruptions and other work system failures … interruptions-and-distractions-healthcare-review-and-reappraisal https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing

331. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38243/psn-pdf
     November 26, 2008 - https://psnet.ahrq.gov/issue/impact-preoperative-briefings-operating-room-delays Communication failures … issue/impact-preoperative-briefings-operating-room-delays https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

332. Where are my instruments? Hazards in delivery of surgical instruments. | PSNet
     psnet.ahrq.gov/issue/where-are-my-instruments-hazards-delivery-surgical-instruments
     September 25, 2008 - March 29, 2023 Reducing failures in daily medical practice: healthcare failure mode … June 1, 2012 Assessing system failures in operating rooms and intensive care units. … Use of failure mode and effects analysis for proactive identification of communication and handoff failures

333. Confidential clinician-reported surveillance of adverse events among medical inpatients. | PSNet
     psnet.ahrq.gov/issue/confidential-clinician-reported-surveillance-adverse-events-among-medical-inpatients
     June 29, 2011 - January 6, 2017 Process of care failures in breast cancer diagnosis. … Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures … August 3, 2022 Using incident reports to assess communication failures and patient outcomes

334. 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

335. 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

336. 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

337. 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

338. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45375/psn-pdf
     September 27, 2016 - association-web-based-handoff-tool-rates-medical-errors Handoffs have been associated with adverse clinical events, largely due to communication failures … statistically significant decrease in the rate of medical errors, particularly errors caused by communication failures

339. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36909/psn-pdf
     January 05, 2017 - medical-team-training-applying-crew-resource-management-veterans-health- administration Communication failures … medical-team-training-applying-crew-resource-management-veterans-health-administration https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

340. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37290/psn-pdf
     February 15, 2011 - distinctive features of errors involving trainees, including teamwork and communication breakdowns, failures … medical-errors-involving-trainees-study-closed-malpractice-claims-5-insurers https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps