Results

Total Results: 7,834 records

Showing results for "failures".

401. Physician engagement in malpractice risk reduction: a UPHS case study. | PSNet
     psnet.ahrq.gov/issue/physician-engagement-malpractice-risk-reduction-uphs-case-study
     June 02, 2019 - Same Author(s) Failure to debrief after critical events in anesthesia is associated with failures … July 19, 2023 Operational failures detected by frontline acute care nurses.

402. Assessment of DoD Wounded Warrior Matters: Managing Risks of Multiple Medications. | PSNet
     psnet.ahrq.gov/issue/assessment-dod-wounded-warrior-matters-managing-risks-multiple-medications
     March 16, 2022 - May 1, 2015 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

403. Advancing patient safety through the clinical application of a framework focused on communication. | PSNet
     psnet.ahrq.gov/issue/advancing-patient-safety-through-clinical-application-framework-focused-communication
     December 02, 2020 - November 26, 2014 Using incident reports to assess communication failures and patient … June 1, 2012 A systematic review of failures in handoff communication during intrahospital

404. Mandatory presuit mediation: 5-year results of a medical malpractice resolution program. | PSNet
     psnet.ahrq.gov/issue/mandatory-presuit-mediation-5-year-results-medical-malpractice-resolution-program
     February 02, 2022 - December 4, 2016 Failure to debrief after critical events in anesthesia is associated with failures … More Related Resources Frequency and nature of communication and handoff failures

405. Clinical perspective: creating an effective practice peer review process—a primer. | PSNet
     psnet.ahrq.gov/issue/clinical-perspective-creating-effective-practice-peer-review-process-primer
     November 16, 2022 - November 11, 2020 Effect of reducing interns' weekly work hours on sleep and attentional failures … The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures

406. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. | PSNet
     psnet.ahrq.gov/issue/evaluation-intervention-aimed-improving-voluntary-incident-reporting-hospitals
     December 16, 2020 - April 14, 2011 Operational failures detected by frontline acute care nurses. … View More Related Resources Using incident reports to assess communication failures

407. Contextual errors in medical decision making: overlooked and understudied. | PSNet
     psnet.ahrq.gov/issue/contextual-errors-medical-decision-making-overlooked-and-understudied
     May 01, 2020 - October 29, 2012 Contextual errors and failures in individualizing patient care: a multicenter … Applying psychological theory to understanding failures in modern healthcare settings.

408. What do hospital staff in the UK think are the causes of penicillin medication errors? | PSNet
     psnet.ahrq.gov/issue/what-do-hospital-staff-uk-think-are-causes-penicillin-medication-errors
     November 16, 2022 - December 4, 2013 An observational study of the frequency, severity, and etiology of failures … September 20, 2012 Identifying the latent failures underpinning medication administration

409. 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

410. Understanding and responding to adverse events. | PSNet
     psnet.ahrq.gov/issue/understanding-and-responding-adverse-events
     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

411. An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions. | PSNet
     psnet.ahrq.gov/issue/evidence-synthesis-perioperative-handoffs-call-balanced-sociotechnical-solutions
     June 23, 2021 - From the Same Author(s) An observational study of postoperative handoff standardization failures … November 17, 2021 An observational study of postoperative handoff standardization failures

412. Potential uses of AI for perioperative nursing handoffs: a qualitative study. | PSNet
     psnet.ahrq.gov/issue/potential-uses-ai-perioperative-nursing-handoffs-qualitative-study
     September 01, 2021 - September 1, 2021 An observational study of postoperative handoff standardization failures … April 26, 2023 An observational study of postoperative handoff standardization failures

413. Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis. | PSNet
     psnet.ahrq.gov/issue/frequency-and-type-situational-awareness-errors-contributing-death-and-brain-damage-closed
     September 01, 2021 - Download Citation Related Resources From the Same Author(s) Communication failures … 18, 2019 Failure to debrief after critical events in anesthesia is associated with failures

414. Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center. | PSNet
     psnet.ahrq.gov/issue/inadequate-emergency-department-care-and-physician-misconduct-washington-dc-va-medical-center
     September 30, 2020 - July 26, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … July 27, 2022 Failures in Care Coordination and Reviewing a Patient's Death at the VA

415. Roles and role ambiguity in patient- and caregiver-performed outpatient parenteral antimicrobial therapy. | PSNet
     psnet.ahrq.gov/issue/roles-and-role-ambiguity-patient-and-caregiver-performed-outpatient-parenteral-antimicrobial
     November 20, 2024 - April 24, 2024 Information management goals and process failures during home visits for … Related Resources An observational study of postoperative handoff standardization failures

416. 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

417. 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

418. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
     psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
     August 01, 2009 - There's bank failures, corporate failures in the auto industry, and health care. … More importantly, operational failures disrupt patient care, leading to uncompleted tasks and medical … Identification of systems failures in successful paediatric cardiac surgery. … The impact of operational failures on hospital nurses and their patients. … Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41:643-662.

419. Bring back the autopsy. | PSNet
     psnet.ahrq.gov/issue/bring-back-autopsy
     September 06, 2016 - Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures … October 25, 2017 Weak oversight allows lab failures to put patients at risk.

420. Prohibition of Excessive Overtime for Nurses Act. | PSNet
     psnet.ahrq.gov/issue/prohibition-excessive-overtime-nurses-act
     August 01, 2007 - September 9, 2011 Process failures that increase the risk of infection through respiratory … January 8, 2020 Patient harm resulting from medication reconciliation process failures