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Total Results: 7,834 records

Showing results for "failures".

421. Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas. | PSNet
     psnet.ahrq.gov/issue/quality-care-concerns-and-facility-response-following-medical-emergency-va-southern-nevada
     July 13, 2022 - Copy Citation Related Resources From the Same Author(s) Multiple Failures … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

422. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. | PSNet
     psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and
     June 24, 2020 - August 7, 2013 View More Related Resources Giving up learning from failures … An examination of learning from one's own failures in the context of heart surgeons.

423. Enteral nutrition: an underappreciated source of patient safety events. | PSNet
     psnet.ahrq.gov/issue/enteral-nutrition-underappreciated-source-patient-safety-events
     February 01, 2023 - March 19, 2008 Operational failures detected by frontline acute care nurses. … Hospitals Nutrition/Dietetics Hospital Medicine Administration Errors Monitoring Errors and Failures

424. Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes. | PSNet
     psnet.ahrq.gov/issue/does-standardisation-improve-post-operative-anaesthesia-handoffs-meta-analyses-provider
     June 29, 2022 - April 28, 2021 Reducing failures in daily medical practice: healthcare failure mode and … July 21, 2021 An observational study of postoperative handoff standardization failures

425. Untenable expectations: nurses' work in the context of medication administration, error, and the organization. | PSNet
     psnet.ahrq.gov/issue/untenable-expectations-nurses-work-context-medication-administration-error-and-organization
     September 21, 2022 - April 7, 2021 Work environment and operational failures associated with nurse outcomes … April 26, 2023 Latent and active failures perfectly align to allow a preventable adverse

426. Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin. | PSNet
     psnet.ahrq.gov/issue/unexpected-death-patient-during-treatment-multiple-medications-tomah-va-medical-center-tomah
     October 12, 2022 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

427. Impact of staff turnover during cardiac surgical procedures. | PSNet
     psnet.ahrq.gov/issue/impact-staff-turnover-during-cardiac-surgical-procedures
     November 06, 2019 - November 17, 2021 An observational study of postoperative handoff standardization failures … August 12, 2020 Deconstructing intraoperative communication failures.

428. Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention. | PSNet
     psnet.ahrq.gov/issue/sustained-improvement-quality-patient-handoffs-after-orthopaedic-surgery-i-pass-intervention
     June 15, 2022 - The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures … March 29, 2023 An observational study of postoperative handoff standardization failures

429. The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm. | PSNet
     psnet.ahrq.gov/issue/new-electronic-health-records-unknown-queue-caused-multiple-events-patient-harm
     October 12, 2022 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … July 26, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

430. Central venous catheter guidewire retention: lessons from England's never event database. | PSNet
     psnet.ahrq.gov/issue/central-venous-catheter-guidewire-retention-lessons-englands-never-event-database
     September 15, 2021 - March 30, 2022 Frequency and nature of communication and handoff failures in medical … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures

431. Health care-associated infections among hospitalized patients with COVID-19, March 2020-March 2022. | PSNet
     psnet.ahrq.gov/issue/health-care-associated-infections-among-hospitalized-patients-covid-19-march-2020-march-2022
     May 12, 2021 - March 7, 2018 Failures in the respectful care of critically ill patients. … November 25, 2020 Process failures that increase the risk of infection through respiratory

432. A quality improvement initiative to improve pediatric discharge medication safety and efficiency. | PSNet
     psnet.ahrq.gov/issue/quality-improvement-initiative-improve-pediatric-discharge-medication-safety-and-efficiency
     May 20, 2020 - April 19, 2023 Operational failures in general practice: a consensus-building study on … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures

433. Medical error: using storytelling and reflection to impact error response factors in family medicine residents. | PSNet
     psnet.ahrq.gov/issue/medical-error-using-storytelling-and-reflection-impact-error-response-factors-family-medicine
     June 05, 2019 - Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures

434. The Child Health PSO at 10 years: an emerging learning network. | PSNet
     psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-learning-network
     July 28, 2021 - Author(s) Health literacy-related safety events: a qualitative study of health literacy failures … 2022 Health literacy-related safety events: a qualitative study of health literacy failures

435. Delays in care during the COVID-19 pandemic in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/delays-care-during-covid-19-pandemic-veterans-health-administration
     May 17, 2023 - January 15, 2025 Operational failures in general practice: a consensus-building study … May 22, 2024 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

436. Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. | PSNet
     psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
     October 12, 2022 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … September 4, 2019 Multiple Failures in Test Results Follow-up for a Patient Diagnosed

437. Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database. | PSNet
     psnet.ahrq.gov/issue/patient-safety-trends-2021-analysis-288882-serious-events-and-incidents-nations-largest-event
     May 19, 2021 - September 1, 2021 Patient harm resulting from medication reconciliation process failures … November 24, 2021 Process failures that increase the risk of infection through respiratory

438. A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics. | PSNet
     psnet.ahrq.gov/issue/systematic-review-prevalence-and-types-adverse-events-interfacility-critical-care-transfers
     November 25, 2020 - August 20, 2018 Routine failures in the process for blood testing and the communication … April 19, 2011 Communication failures in patient sign-out and suggestions for improvement

439. Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri. | PSNet
     psnet.ahrq.gov/issue/deficiencies-inpatient-mental-health-care-coordination-and-processes-prior-patients-death
     May 26, 2021 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … January 29, 2020 Failures in Care Coordination and Reviewing a Patient's Death at the

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49814/psn-pdf
     December 01, 2017 - web-mm/miscommunication-or-leads-anticoagulation-mishap As highlighted by this case, communication failures … In one study exploring OR communication failures, researchers found that they were present in approximately … optimal safety culture is challenging: no single intervention can address all communication-related failures … Communication failures in the operating room: an observational classification of recurrent types and … Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186-194.