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Showing results for "failures".

41. Assessing system failures in operating rooms and intensive care units. | PSNet
    psnet.ahrq.gov/issue/assessing-system-failures-operating-rooms-and-intensive-care-units
    June 15, 2011 - Study Assessing system failures in operating rooms and intensive care units. … Assessing system failures in operating rooms and intensive care units. … The authors describe an instrument for identifying failures in the intensive care unit (ICU) and operating … room to help organizations gain insight into system failures in those high-risk environments. … Assessing system failures in operating rooms and intensive care units.

42. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836852/psn-pdf
    April 06, 2022 - Frequency and nature of communication and handoff failures in medical malpractice claims. … Frequency and nature of communication and handoff failures in medical malpractice claims. … https://psnet.ahrq.gov/issue/frequency-and-nature-communication-and-handoff-failures-medical- malpractice-claims … play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures … https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report

43. 5 pandemic mistakes we keep repeating. We can learn from our failures. | PSNet
    psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures
    March 10, 2021 - We can learn from our failures. Citation Text: 5 pandemic mistakes we keep repeating. … We can learn from our failures. Zeynep Tufekci. The Atlantic. … February 26, 2021 Failures in communication have impacts on patients, teams, organizations and … We can learn from our failures. Zeynep Tufekci. The Atlantic.

44. When things go wrong: how health care organizations deal with major failures. | PSNet
    psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures
    March 13, 2013 - Classic When things go wrong: how health care organizations deal with major failures … When things go wrong: how health care organizations deal with major failures. … The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the … reporting and investigation mechanisms, and greater transparency in both reporting and responding to major failures … When things go wrong: how health care organizations deal with major failures.

45. Identifying the latent failures underpinning medication administration errors: an exploratory study. | PSNet
    psnet.ahrq.gov/issue/identifying-latent-failures-underpinning-medication-administration-errors-exploratory-study
    December 21, 2016 - Study Identifying the latent failures underpinning medication administration errors … Identifying the latent failures underpinning medication administration errors: an exploratory study. … This study identified 10 latent failures that contributed to medication administration errors based … Ward climate , the most prevalent theme, was noted to interact with other failures such as workload … Identifying the latent failures underpinning medication administration errors: an exploratory study.

46. A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network. | PSNet
    psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-procurement-and
    August 10, 2022 - Congressional Testimony A System in Need of Repair: Addressing Organizational Failures … Citation Text: A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement … Blood-type mistakes , transport failures, and process challenges were amongst the problems discussed. … Citation Citation Text: A System in Need of Repair: Addressing Organizational Failures

47. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60987/psn-pdf
    October 07, 2020 - Process failures that increase the risk of infection through respiratory droplets: a study of patient … Process failures that increase the risk of infection through respiratory droplets: a study of patient … https://psnet.ahrq.gov/issue/process-failures-increase-risk-infection-through-respiratory-droplets-study … - patient-safety In an effort to identify process failures related to infectious disease spread in … The analysis identified several process failures, most commonly involving the testing or processing

48. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73657/psn-pdf
    September 01, 2021 - Communication failures contributing to patient injury in anaesthesia malpractice claims. … Communication failures contributing to patient injury in anaesthesia malpractice claims. … https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice … https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims … https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims

49. Frequency and nature of communication and handoff failures in medical malpractice claims. | PSNet
    psnet.ahrq.gov/issue/frequency-and-nature-communication-and-handoff-failures-medical-malpractice-claims
    June 22, 2022 - Study Frequency and nature of communication and handoff failures in medical malpractice … Frequency and nature of communication and handoff failures in medical malpractice claims. … play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures … Frequency and nature of communication and handoff failures in medical malpractice claims.

50. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73417/psn-pdf
    June 23, 2021 - Classification of failures in the perception of conversational agents (CAs) and their implications on … Classification of failures in the perception of conversational agents (CAs) and their implications on … https://psnet.ahrq.gov/issue/classification-failures-perception-conversational-agents-cas-and-their- … Investigators used these CAs to detect errors and failures in calculating correct insulin doses. … Potential failures must be considered before deployment of CAs in safety-critical environments.

51. Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals. | PSNet
    psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events
    October 07, 2020 - Study Patient harm resulting from medication reconciliation process failures: a study … Patient harm resulting from medication reconciliation process failures: a study of serious events reported … The most common process failures contributing to patient harm occurred during order entry/transcription … Patient harm resulting from medication reconciliation process failures: a study of serious events reported … Download Citation Related Resources From the Same Author(s) Process failures

52. Failures in communication and information transfer across the surgical care pathway: interview study. | PSNet
    psnet.ahrq.gov/issue/failures-communication-and-information-transfer-across-surgical-care-pathway-interview-study
    August 09, 2013 - Study Failures in communication and information transfer across the surgical care … Failures in communication and information transfer across the surgical care pathway: interview study. … This qualitative study found considerable evidence for communication failures between clinicians at … Failures in communication and information transfer across the surgical care pathway: interview study. … July 6, 2012 An observational study of the frequency, severity, and etiology of failures

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47921/psn-pdf
    June 18, 2019 - Using incident reports to assess communication failures and patient outcomes. … Using Incident Reports to Assess Communication Failures and Patient Outcomes. … https://psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes … Communication failures are a common underlying factor in adverse events. … /issue/communication-failures-operating-room-observational-classification-recurrent-types-and https:/

54. Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography. | PSNet
    psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures-detect-foreign
    April 03, 2017 - Commentary Profiles in patient safety: misplaced femoral line guidewire and multiple failures … Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures to Detect the Foreign … report, the authors discuss a series of errors and illustrate the concepts of active  and latent failures … Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures to Detect the Foreign … Diagnoses of Cancer July 31, 2023 Preventing and mitigating radiology system failures

55. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. | PSNet
    psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
    November 16, 2022 - The model discussed focuses on two types of failures, which share equal importance in analysis but distinguish … The first, active failures , consists of mistakes made by providers in the delivery of care. … The second, latent failures , represents flaws in the systems of care. … The authors use a case example in anesthesia to illustrate how searching for active failures alone fails … analysis of past disasters has offered a useful model to differentiate provider from organizational failures

56. Trainees' perceptions of patient safety practices: recounting failures of supervision. | PSNet
    psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision
    September 20, 2011 - Study Trainees' perceptions of patient safety practices: recounting failures of supervision … Trainees' perceptions of patient safety practices: recounting failures of supervision. … Trainees' perceptions of patient safety practices: recounting failures of supervision.

57. Syndromic surveillance for health information system failures: a feasibility study. | PSNet
    psnet.ahrq.gov/issue/syndromic-surveillance-health-information-system-failures-feasibility-study
    November 03, 2015 - Study Syndromic surveillance for health information system failures: a feasibility … Syndromic surveillance for health information system failures: a feasibility study. … Syndromic surveillance for health information system failures: a feasibility study. … November 2, 2010 A systematic review of failures in handoff communication during intrahospital

58. Preventing and mitigating radiology system failures: a guide to disaster planning. | PSNet
    psnet.ahrq.gov/issue/preventing-and-mitigating-radiology-system-failures-guide-disaster-planning
    November 23, 2016 - Commentary Preventing and mitigating radiology system failures: a guide to disaster … Preventing and mitigating radiology system failures: a guide to disaster planning. … hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures … Preventing and mitigating radiology system failures: a guide to disaster planning. … February 9, 2011 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

59. Effect of reducing interns' weekly work hours on sleep and attentional failures. | PSNet
    psnet.ahrq.gov/issue/effect-reducing-interns-weekly-work-hours-sleep-and-attentional-failures
    January 10, 2017 - Study Effect of reducing interns' weekly work hours on sleep and attentional failures … Effect of reducing interns' weekly work hours on sleep and attentional failures. … that limiting intern work hours to less than 80 hours per week led to more sleep and less attentional failures … least one electrooculophaphy-derived slow eye movement while at work, a validated marker for attention failures … Effect of reducing interns' weekly work hours on sleep and attentional failures.

60. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72537/psn-pdf
    December 02, 2020 - Automation failures and patient safety. December 2, 2020 Ruskin KJ, Ruskin AC, O’Connor M. … Automation failures and patient safety. … https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety Task automation in medicine is a … This review examines automation failures in anesthesiology. … https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety https://psnet.ahrq.gov/issue/role-automation-complex-system-failures