Results

Total Results: 7,834 records

Showing results for "failures".

341. 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

342. Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery. | PSNet
     psnet.ahrq.gov/issue/locating-errors-through-networked-surveillance-multimethod-approach-peer-assessment-hazard
     May 24, 2012 - 22, 2017 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

343. Safety culture in cardiac surgical teams: data from five programs and national surgical comparison. | PSNet
     psnet.ahrq.gov/issue/safety-culture-cardiac-surgical-teams-data-five-programs-and-national-surgical-comparison
     May 24, 2012 - 25, 2010 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

344. 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

345. 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

346. Anatomy and pathophysiology of errors occurring in clinical radiology practice. | PSNet
     psnet.ahrq.gov/issue/anatomy-and-pathophysiology-errors-occurring-clinical-radiology-practice
     February 01, 2011 - diagnostic errors in radiology and describes a classification scheme to identify and prevent potential failures … 14, 2011 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

347. Patient Safety Authority. | PSNet
     psnet.ahrq.gov/issue/patient-safety-authority
     October 07, 2020 - Pennsylvania Copy Citation Related Resources From the Same Author(s) Process failures … October 7, 2020 Patient harm resulting from medication reconciliation process failures

348. 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

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46652/psn-pdf
     July 14, 2018 - effects-crew-resource-management-teamwork-and-safety-climate-veterans- health-administration Communication failures … effects-crew-resource-management-teamwork-and-safety-climate-veterans-health-administration https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

350. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34775/psn-pdf
     February 07, 2019 - attendees, Berwick uses the story of the Mann Gulch Fire tragedy  to frame a series of reflections on the failures … He builds on the anecdotes by describing factors that contribute to an organization’s failures, once

351. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37771/psn-pdf
     June 29, 2011 - effect-crew-resource-management-training-multidisciplinary-obstetrical-setting Teamwork and communication failures … potential-improved-teamwork-reduce-medical-errors-emergency-department https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

352. Improving patient safety in clinical oncology: applying lessons from Normal Accident Theory. | PSNet
     psnet.ahrq.gov/issue/improving-patient-safety-clinical-oncology-applying-lessons-normal-accident-theory
     September 27, 2016 - The Normal Accident Theory suggests that failures are inevitable in complex environments, but proactive … analysis of potential failures within systems can identify improvement strategies.

353. Strategies for improving communication in the emergency department: mediums and messages in a noisy environment. | PSNet
     psnet.ahrq.gov/issue/strategies-improving-communication-emergency-department-mediums-and-messages-noisy
     November 17, 2010 - Discussing how noise and communication failures in the emergency department affect patients and clinicians … Werner, PhD November 16, 2022 Preventing and mitigating radiology system failures

354. Use of a human factors classification framework to identify causal factors for medication and medical device-related adverse clinical incidents. | PSNet
     psnet.ahrq.gov/issue/use-human-factors-classification-framework-identify-causal-factors-medication-and-medical
     March 16, 2016 - involved staff actions that led to mistakes, whereas the device incidents were often related to equipment failures … July 20, 2009 Process of care failures in breast cancer diagnosis.

355. Unintended errors with EHR-based result management: a case series. | PSNet
     psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-series
     April 29, 2018 - may occur with electronic test result systems and describe improvement strategies to address such failures … April 3, 2024 View More Related Resources Operational failures

356. A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability. | PSNet
     psnet.ahrq.gov/issue/theory-based-instrument-evaluate-team-communication-operating-room-balancing-measurement
     June 23, 2010 - This study describes the process of developing a tool to measure communication failures in the operating … September 21, 2011 Communication failures in the operating room: an observational classification

357. An IDEA: safety training to improve critical thinking by individuals and teams. | PSNet
     psnet.ahrq.gov/issue/idea-safety-training-improve-critical-thinking-individuals-and-teams
     May 25, 2016 - Diagnostic improvement leaders have advocated for emphasis on cognition to reduce failures. … January 12, 2022 Operational failures detected by frontline acute care nurses.

358. Violations of behavioral practices revealed in closed claims reviews. | PSNet
     psnet.ahrq.gov/issue/violations-behavioral-practices-revealed-closed-claims-reviews
     August 26, 2011 - This study adds to those concerns by finding that failures in behavioral practice occurred in nearly … August 4, 2021 Communication failures contributing to patient injury in anaesthesia malpractice

359. 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

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39523/psn-pdf
     September 26, 2016 - administration and discovered that each interruption was associated with a 12.1% increase in procedural failures … association-interruptions-increased-risk-and-severity-medication-administration-errors https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing