Results

Total Results: 8,190 records

Showing results for "failures".

381. 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

382. 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

383. 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

384. 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.

385. Improving reliability with root cause analysis. | PSNet
     psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis
     January 17, 2017 - 14, 2005 Profiles in patient safety: misplaced femoral line guidewire and multiple failures … July 22, 2020 Multiple latent failures align to allow a serious drug interaction to harm

386. Annual Benchmarking Report: Malpractice Risks in Surgery. | PSNet
     psnet.ahrq.gov/issue/annual-benchmarking-report-malpractice-risks-surgery
     July 18, 2018 - June 24, 2020 Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report … August 24, 2022 Communication failures contributing to patient injury in anaesthesia

387. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy. | PSNet
     psnet.ahrq.gov/issue/current-state-diagnostic-safety-implications-research-practice-and-policy
     August 07, 2024 - August 9, 2024 Operational failures in general practice: a consensus-building study on … August 16, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

388. The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide. | PSNet
     psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide
     January 09, 2025 - 2022 Health literacy-related safety events: a qualitative study of health literacy failures … September 30, 2020 Multiple latent failures align to allow a serious drug interaction

389. A brief analysis of telemetry–related events. | PSNet
     psnet.ahrq.gov/issue/brief-analysis-telemetry-related-events
     October 07, 2020 - Copy Citation Related Resources From the Same Author(s) Process failures … September 19, 2016 Patient harm resulting from medication reconciliation process failures

390. Assessing medication safety in settings not designated solely for pediatric patients. | PSNet
     psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
     February 01, 2023 - Copy Citation Related Resources From the Same Author(s) Latent and active failures … February 8, 2023 Latent and active failures perfectly align to allow a preventable adverse

391. Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke. | PSNet
     psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-thrombolysis-acute
     November 13, 2019 - March 1, 2023 Clinical Investigation Booking Systems Failures: Written Communications … June 14, 2023 Clinical Investigation Booking Systems Failures: Written Communications

392. Unprofessional Behavior Leads to Complications. | PSNet
     psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications
     June 03, 2020 - June 3, 2020 Closing the loop on test results to reduce communication failures: a rapid … March 31, 2021 Using trainee failures to enhance learning: a qualitative study of pediatric

393. Examining the Status of VA’s Electronic Health Record Modernization Program. | PSNet
     psnet.ahrq.gov/issue/examining-status-vas-electronic-health-record-modernization-program
     November 10, 2021 - November 10, 2021 A System in Need of Repair: Addressing Organizational Failures of the … October 12, 2022 A System in Need of Repair: Addressing Organizational Failures of the

394. 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

395. Clinical information technologies and inpatient outcomes: a multiple hospital study. | PSNet
     psnet.ahrq.gov/issue/clinical-information-technologies-and-inpatient-outcomes-multiple-hospital-study
     October 14, 2009 - in clinical outcomes associated with computerized provider order entry , but other high-profile failures … August 18, 2021 Operational failures detected by frontline acute care nurses.

396. Cause and effect analysis of closed claims in obstetrics and gynecology. | PSNet
     psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-obstetrics-and-gynecology
     April 05, 2017 - the majority of cases, investigators identified at least one preventable factor, with communication failures … April 5, 2017 Operational failures and interruptions in hospital nursing.

397. Teaching Clinical Reasoning. | PSNet
     psnet.ahrq.gov/issue/teaching-clinical-reasoning
     August 20, 2018 - February 15, 2010 The role of automation in complex system failures. … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures

398. An Amendment of the Medical Care Availability and Reduction of Error (Mcare) Act. | PSNet
     psnet.ahrq.gov/issue/amendment-medical-care-availability-and-reduction-error-mcare-act
     June 03, 2009 - June 27, 2007 Process failures that increase the risk of infection through respiratory … December 9, 2020 Patient harm resulting from medication reconciliation process failures

399. Medication administration errors by nurses: adherence to guidelines. | PSNet
     psnet.ahrq.gov/issue/medication-administration-errors-nurses-adherence-guidelines
     July 08, 2020 - Related Resources Impact of interruptions, distractions, and cognitive load on procedure failures … August 20, 2014 Identifying the latent failures underpinning medication administration

400. Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study. | PSNet
     psnet.ahrq.gov/issue/factors-influencing-diagnostic-accuracy-among-intensive-care-unit-clinicians-observational
     October 24, 2018 - April 28, 2021 Failures in the respectful care of critically ill patients. … June 19, 2019 Inattentional blindness and failures to rescue the deteriorating patient