Results

Total Results: 8,190 records

Showing results for "failures".

421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38827/psn-pdf
     January 23, 2019 - explains how shifting liability from individual physicians to hospitals could deter systems-based failures

422. 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

423. 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.

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38667/psn-pdf
     June 16, 2019 - monthly selection of medication error reports includes examples of drug name confusion, communication failures

425. 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

426. 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

427. 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

428. 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.

429. 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

430. 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

431. 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

432. 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

433. 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

434. Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice. | PSNet
     psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line
     May 24, 2016 - From the Same Author(s) Work Design Drivers of Organizational Learning about Operational Failures … July 8, 2016 Work Design Drivers of Organizational Learning about Operational Failures

435. High reliability: excellent care every time. | PSNet
     psnet.ahrq.gov/issue/high-reliability-excellent-care-every-time
     July 19, 2018 - June 10, 2018 Reducing interdisciplinary communication failures through secure text messaging … August 12, 2015 Inquiry into reporter's death finds multiple failures in care.

436. 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.

437. Application of failure mode and effect analysis in a radiology department. | PSNet
     psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department
     October 13, 2010 - August 10, 2022 Preventing and mitigating radiology system failures: a guide to disaster … July 1, 2009 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

438. Failure mode and effects analysis: a comparison of two common risk prioritisation methods. | PSNet
     psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-comparison-two-common-risk-prioritisation-methods
     September 09, 2015 - August 31, 2022 Reducing failures in daily medical practice: healthcare failure mode … April 24, 2018 Preventing blood transfusion failures: FMEA, an effective assessment method

439. Using HFMEA to assess potential for patient harm from tubing misconnections. | PSNet
     psnet.ahrq.gov/issue/using-hfmea-assess-potential-patient-harm-tubing-misconnections
     April 19, 2013 - October 12, 2022 Impacts of operational failures on primary care physicians' work: a … November 16, 2022 Preventing adverse events caused by emergency electrical power system failures

440. Governing the surgical count through communication interactions: implications for patient safety. | PSNet
     psnet.ahrq.gov/issue/governing-surgical-count-through-communication-interactions-implications-patient-safety
     November 06, 2015 - RIS Download Citation Related Resources From the Same Author(s) Failures … October 11, 2023 Operational failures detected by frontline acute care nurses.