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Total Results: 8,190 records

Showing results for "failures".

361. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38116/psn-pdf
     February 18, 2011 - /psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures … /psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures

362. 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

363. Veterans Accountability Improvement Act. | PSNet
     psnet.ahrq.gov/issue/veterans-accountability-improvement-act
     March 25, 2020 - March 25, 2020 A System in Need of Repair: Addressing Organizational Failures of the … May 4, 2022 Pathology Oversight Failures at the Veterans Health Care System of the Ozarks

364. How reliable are clinical systems in the UK NHS? A study of seven NHS organisations. | PSNet
     psnet.ahrq.gov/issue/how-reliable-are-clinical-systems-uk-nhs-study-seven-nhs-organisations
     November 26, 2008 - February 8, 2017 Identifying systems failures in the pathway to a catastrophic event: … August 12, 2014 Surgical technology and operating-room safety failures: a systematic … August 13, 2013 An observational study of the frequency, severity, and etiology of failures

365. 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.

366. 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

367. 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.

368. 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

369. 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

370. 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.

371. 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

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37387/psn-pdf
     January 10, 2017 - management (CRM) methods to health care settings has been driven by noted teamwork and communication failures … potential-improved-teamwork-reduce-medical-errors-emergency-department https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

373. Clear liquids may place patients at risk. | PSNet
     psnet.ahrq.gov/issue/clear-liquids-may-place-patients-risk
     May 19, 2021 - November 11, 2020 Process failures that increase the risk of infection through respiratory … October 7, 2020 Patient harm resulting from medication reconciliation process failures

374. The Diagnosis of Ectopic Pregnancy. | PSNet
     psnet.ahrq.gov/issue/diagnosis-ectopic-pregnancy
     April 26, 2023 - March 1, 2023 Clinical Investigation Booking Systems Failures: Written Communications … June 14, 2023 Clinical Investigation Booking Systems Failures: Written Communications

375. Patients with low health literacy make more errors interpreting instructions and warnings. | PSNet
     psnet.ahrq.gov/issue/patients-low-health-literacy-make-more-errors-interpreting-instructions-and-warnings
     May 03, 2023 - , 2023 Patient death tied to lack of proper escalation process for barcode scanning failures … March 14, 2023 Latent and active failures perfectly align to allow a preventable adverse

376. Escape Fire: Lessons for the Future of Health Care. | PSNet
     psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care
     July 05, 2008 - 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

377. Liquid-based Papanicolaou tests in endometrial carcinoma diagnosis: performance, error root cause analysis, and quality improvement. | PSNet
     psnet.ahrq.gov/issue/liquid-based-papanicolaou-tests-endometrial-carcinoma-diagnosis-performance-error-root-cause
     September 01, 2012 - Through root cause analysis , latent and active failures were identified, and several quality improvement … September 1, 2012 Frequency and outcome of cervical cancer prevention failures in the

378. Science and patient safety. | PSNet
     psnet.ahrq.gov/issue/science-and-patient-safety
     July 19, 2019 - July 15, 2015 Surgical technology and operating-room safety failures: a systematic review … April 12, 2011 An observational study of the frequency, severity, and etiology of failures

379. Implement strategies to prevent persistent medication errors and hazards. | PSNet
     psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards
     March 14, 2023 - May 3, 2023 Latent and active failures perfectly align to allow a preventable adverse … November 1, 2023 Latent and active failures perfectly align to allow a preventable adverse

380. Concurrent and Overlapping Surgeries: Additional Measures Warranted. | PSNet
     psnet.ahrq.gov/issue/concurrent-and-overlapping-surgeries-additional-measures-warranted
     August 17, 2022 - Resources From the Same Author(s) A System in Need of Repair: Addressing Organizational Failures … More Related Resources A System in Need of Repair: Addressing Organizational Failures