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Total Results: 7,834 records

Showing results for "failures".

361. 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

362. 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

363. Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study. | PSNet
     psnet.ahrq.gov/issue/hospital-acquired-functional-decline-and-clinical-outcomes-older-cardiac-surgical-patients
     February 06, 2019 - 19, 2021 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

364. 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

365. Swiss Cheese Model | PSNet
     psnet.ahrq.gov/glossary/swiss-cheese-model
     September 13, 2021 - developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures … tend to reveal multiple, smaller failures leading up to the actual hazard.

366. 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

367. 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

368. 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

369. 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

370. 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

371. 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

372. 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

373. 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

374. 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

375. Preventing medical injury. | PSNet
     psnet.ahrq.gov/issue/preventing-medical-injury
     February 18, 2011 - The most common types of preventable events are technical errors, errors in diagnosis, failures of prevention … Diagnostic mishaps and late surgical failures had the highest rates of preventability.

376. Evidence that nurses need to participate in diagnosis: lessons from malpractice claims. | PSNet
     psnet.ahrq.gov/issue/evidence-nurses-need-participate-diagnosis-lessons-malpractice-claims
     September 12, 2018 - included inadequate communication among providers (55%), failure to respond (41%), and documentation failures … Both diagnosis-related and physiologic monitoring cases listing communication failures among providers

377. A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy. | PSNet
     psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy
     June 13, 2011 - in an organization, analyze the ways in which processes can fail, and take corrective action before failures … View More Related Resources Preventing and mitigating radiology system failures

378. High Reliability | PSNet
     psnet.ahrq.gov/primer/high-reliability
     January 29, 2020 - 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

379. VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout. | PSNet
     psnet.ahrq.gov/issue/va-pauses-16b-oracle-cerner-ehr-deployments-indefinitely-address-error-ridden-early-rollout
     September 14, 2022 - May 3, 2023 Clinical Investigation Booking Systems Failures: Written Communications in … Improve Management of Sepsis May 31, 2023 Clinical Investigation Booking Systems Failures

380. 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