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psnet.ahrq.gov/issue/do-safety-checklists-improve-teamwork-and-communication-operating-room-systematic-review
January 19, 2016 - May 30, 2012
Surgical technology and operating-room safety failures: a systematic review … August 11, 2010
Failures in communication and information transfer across the surgical
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psnet.ahrq.gov/issue/using-computerized-sign-out-system-improve-physician-nurse-communication
September 28, 2016 - August 21, 2019
Using incident reports to assess communication failures and patient outcomes … January 23, 2017
Failures in communication through documents and documentation across
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psnet.ahrq.gov/issue/predictors-unit-level-medication-administration-accuracy-microsystem-impacts-medication
October 06, 2016 - April 24, 2018
Operational failures detected by frontline acute care nurses. … September 26, 2016
Operational failures and interruptions in hospital nursing.
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psnet.ahrq.gov/issue/recovery-medical-errors-critical-care-nursing-safety-net
February 18, 2011 - June 29, 2009
Effect of reducing interns' weekly work hours on sleep and attentional failures … One Bronchoscopy, Two Errors
January 1, 2019
Inattentional blindness and failures
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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
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psnet.ahrq.gov/issue/just-culture-its-more-policy
July 05, 2017 - Download Citation
Related Resources From the Same Author(s)
Operational failures … 11, 2018
Failure to debrief after critical events in anesthesia is associated with failures
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psnet.ahrq.gov/issue/surgical-crisis-management-skills-training-and-assessment-stimulation-based-approach
March 03, 2011 - April 11, 2009
Surgical technology and operating-room safety failures: a systematic review … June 1, 2016
Failures in communication and information transfer across the surgical care
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psnet.ahrq.gov/issue/patient-safety-attitudes-and-behaviors-graduating-medical-students
June 01, 2016 - November 16, 2022
Decreasing handoff-related care failures in children's hospitals. … October 31, 2018
Trainees' perceptions of patient safety practices: recounting failures
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psnet.ahrq.gov/issue/introducing-safety-score-audit-staff-member-and-patient-safety
April 16, 2014 - April 16, 2014
Operational failures in general practice: a consensus-building study on … August 20, 2018
Impacts of operational failures on primary care physicians' work: a critical
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psnet.ahrq.gov/issue/team-communication-during-patient-handover-operating-room-more-facts-and-figures
December 16, 2009 - April 3, 2013
Deconstructing intraoperative communication failures. … Use of failure mode and effects analysis for proactive identification of communication and handoff failures
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psnet.ahrq.gov/issue/nexus-nursing-leadership-and-culture-safer-patient-care
January 18, 2018 - September 3, 2011
Operational failures detected by frontline acute care nurses. … October 4, 2017
Failures in communication through documents and documentation across
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psnet.ahrq.gov/issue/patient-safety-otolaryngology-descriptive-review
July 14, 2010 - January 14, 2014
Surgical technology and operating-room safety failures: a systematic … August 13, 2013
Deconstructing intraoperative communication failures.
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psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis
July 13, 2010 - June 23, 2009
Communication failures contributing to patient injury in anaesthesia malpractice … September 21, 2022
Communication failures contributing to patient injury in anaesthesia
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psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
June 21, 2016 - November 12, 2014
Decreasing handoff-related care failures in children's hospitals. … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures
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psnet.ahrq.gov/issue/systematic-proactive-risk-assessment-hazards-surgical-wards-quantitative-study
August 15, 2013 - April 27, 2019
View More
Related Resources
Reducing failures in … Use of failure mode and effects analysis for proactive identification of communication and handoff failures
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psnet.ahrq.gov/issue/test-result-communication-primary-care-survey-current-practice
November 20, 2015 - Download Citation
Related Resources From the Same Author(s)
Routine failures … May 22, 2019
Routine failures in the process for blood testing and the communication
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - medication errors
Describe a model for a systems approach to error analysis
Identify weaknesses or failures … Approach to Medication Errors
The goal of a systems-based analysis of errors is to identify system failures … errors should use the ISMP model (see slide 10)
Applying the framework to this case reveals numerous failures … id=51
20
This Case
This case highlights the multiple systems failures.
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psnet.ahrq.gov/issue/causes-medication-administration-errors-hospitals-systematic-review-quantitative-and
April 01, 2015 - September 29, 2017
Impact of interruptions, distractions, and cognitive load on procedure failures … March 13, 2013
Identifying the latent failures underpinning medication administration
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psnet.ahrq.gov/issue/modifying-head-nurse-messages-during-daily-conversations-leverage-safety-climate-improvement
August 26, 2011 - View More
Related Resources
Using incident reports to assess communication failures … October 27, 2016
Failures in communication through documents and documentation across
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psnet.ahrq.gov/issue/parents-perspectives-keeping-their-children-safe-hospital
June 27, 2018 - June 27, 2018
Operational failures detected by frontline acute care nurses. … July 5, 2017
Participating in a multisite study exploring operational failures encountered