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Total Results: 8,190 records

Showing results for "failures".

341. 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

342. 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

343. 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

344. 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

345. Contingency planning for electronic health record–based care continuity: a survey of recommended practices. | PSNet
     psnet.ahrq.gov/issue/contingency-planning-electronic-health-record-based-care-continuity-survey-recommended
     November 11, 2020 - 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

346. Using failure mode and effects analysis to increase patient safety in cancer chemotherapy. | PSNet
     psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-increase-patient-safety-cancer-chemotherapy
     August 18, 2021 - Using failure mode and effects analysis (FMEA), researchers identified potential failures related to … Common failures included incorrect patient information, non-standardized chemotherapy protocols, and

347. Analyzing and discussing human factors affecting surgical patient safety using innovative technology: creating a safer operating culture. | PSNet
     psnet.ahrq.gov/issue/analyzing-and-discussing-human-factors-affecting-surgical-patient-safety-using-innovative
     August 25, 2021 - These events primarily involved communication failures, poor teamwork, and situational awareness failures

348. Perspectives on anesthesia and perioperative patient safety: past, present, and future. | PSNet
     psnet.ahrq.gov/issue/perspectives-anesthesia-and-perioperative-patient-safety-past-present-and-future
     June 19, 2019 - Achieving sustained improvements in patient safety requires learning from both safety failures and … The Safety I framework includes using individual and system failures, analytics, culture, and technology

349. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. | PSNet
     psnet.ahrq.gov/issue/risk-assessment-acute-stroke-diagnostic-process-using-failure-modes-effects-and-criticality
     July 21, 2021 - effects, and criticality analysis (FMECA) to create an acute stroke diagnostic process map, identify failures … The FMECA process identified several steps in the diagnostic process as the most critical failures to

350. Barriers to incident-reporting behavior among nursing staff: a study based on the theory of planned behavior. | PSNet
     psnet.ahrq.gov/issue/barriers-incident-reporting-behavior-among-nursing-staff-study-based-theory-planned-behavior
     February 27, 2019 - Incident reporting systems are an important method for identifying system failures that expose patients … July 10, 2017 Operational failures detected by frontline acute care nurses.

351. Lax oversight leaves surgery center regulators and patients in the dark. | PSNet
     psnet.ahrq.gov/issue/lax-oversight-leaves-surgery-center-regulators-and-patients-dark
     May 17, 2017 - High-profile failures during office-based procedures have raised awareness of the potential safety hazards … Enhanced transparency regarding those failures can enable informed patient decision-making when choosing

352. Incidents during out-of-hospital patient transportation. | PSNet
     psnet.ahrq.gov/issue/incidents-during-out-hospital-patient-transportation
     March 23, 2011 - They found that 91% of reported failures were preventable and conclude that incident monitoring is an … Improving patient safety governance and systems through learning from successes and failures

353. The Safety of Maternity Services in England. | PSNet
     psnet.ahrq.gov/issue/safety-maternity-services-england
     February 04, 2015 - High-profile failures motivate examination and change of existing services. … This report builds on maternity care failures in National Health Service trusts to recommend needed

354. Communication failure in the operating room. | PSNet
     psnet.ahrq.gov/issue/communication-failure-operating-room
     February 25, 2009 - Communication failures are a well-characterized source of errors in the operating room. … in this study, implementation of a teamwork training program was associated with fewer communication failures

355. 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

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37543/psn-pdf
     March 03, 2011 - Although extended shifts were associated with self-reported attentional failures in one study, other … /psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures

357. 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

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49415/psn-pdf
     September 01, 2003 - 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 … 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.

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40092/psn-pdf
     December 22, 2010 - value-adding-verbal-report-written-handoffs-early-readmission-following- prolonged-respiratory Teamwork and communication failures … Intensive care units (ICU) have demonstrated the impact of different strategies to address these failures

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43869/psn-pdf
     November 03, 2015 - The researchers found that while most events were technical failures, incidents involving human errors … Technical failures affecting 10 or more patients accounted for nearly 25% of events and were more likely