Results

Total Results: 7,834 records

Showing results for "failures".

81. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/74722/psn-pdf
    February 02, 2022 - Preventing and mitigating radiology system failures: a guide to disaster planning. … Preventing and mitigating radiology system failures: a guide to disaster planning. … https://psnet.ahrq.gov/issue/preventing-and-mitigating-radiology-system-failures-guide-disaster-planning … hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures … https://psnet.ahrq.gov/issue/preventing-and-mitigating-radiology-system-failures-guide-disaster-planning

82. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837866/psn-pdf
    August 17, 2022 - A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and … https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ- procurement-and … Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed. … https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-procurement-and … https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-procurement-and

83. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36021/psn-pdf
    September 24, 2016 - Operational failures and interruptions in hospital nursing. … Operational failures and interruptions in hospital nursing. … https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing This study discovered … that nurses experienced more than eight work system failures during an 8-hour shift. … The most frequent failures identified involved medications, orders, supplies, staffing, and equipment

84. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/857452/psn-pdf
    December 06, 2023 - Improving patient safety governance and systems through learning from successes and failures: qualitative … Improving patient safety governance and systems through learning from successes and failures: qualitative … psnet.ahrq.gov/issue/improving-patient-safety-governance-and-systems-through-learning- successes-and-failures … psnet.ahrq.gov/issue/improving-patient-safety-governance-and-systems-through-learning-successes-and-failures … psnet.ahrq.gov/issue/improving-patient-safety-governance-and-systems-through-learning-successes-and-failures

85. "What's psychology got to do with it?" Applying psychological theory to understanding failures in modern healthcare settings. | PSNet
    psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern
    July 10, 2017 - Applying psychological theory to understanding failures in modern healthcare settings. … Applying psychological theory to understanding failures in modern healthcare settings. … from psychology , including theories related to behavior and cognition , to understand why care failures … Applying psychological theory to understanding failures in modern healthcare settings.

86. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837677/psn-pdf
    July 13, 2022 - Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton … https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer- … hampton-va-medical Cancer test communication failures can contribute to physical, emotional, and financial … https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical … https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical

87. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/844047/psn-pdf
    February 08, 2023 - Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing … Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing … https://psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists … https://psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists-allowing … https://psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists-allowing

88. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46036/psn-pdf
    July 05, 2017 - Operational failures detected by frontline acute care nurses. … Operational Failures Detected by Frontline Acute Care Nurses. … https://psnet.ahrq.gov/issue/operational-failures-detected-frontline-acute-care-nurses This prospective … reporting study asked frontline nurse participants to record operational failures, or breakdowns in … Nurses recorded about six such failures per shift, suggesting that systems failures are common in acute

89. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41228/psn-pdf
    August 02, 2012 - Identifying the latent failures underpinning medication administration errors: an exploratory study. … Identifying the latent failures underpinning medication administration errors: an exploratory study. … https://psnet.ahrq.gov/issue/identifying-latent-failures-underpinning-medication-administration-errors … - exploratory-study This study identified 10 latent failures that contributed to medication administration … Ward climate, the most prevalent theme, was noted to interact with other failures such as workload,

90. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46920/psn-pdf
    August 08, 2018 - Identification and characterization of failures in infectious agent transmission precaution practices … Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices … https://psnet.ahrq.gov/issue/identification-and-characterization-failures-infectious-agent-transmission … This direct observation study observed frequent failures in use of PPE, including entering rooms without … The authors suggest that given the wide range of failures, a variety of strategies are needed to improve

91. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73371/psn-pdf
    June 09, 2021 - Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … https://psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect … https://psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect-analysis-combined … https://psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect-analysis-combined

92. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36703/psn-pdf
    March 28, 2011 - Assessing system failures in operating rooms and intensive care units. … Assessing system failures in operating rooms and intensive care units. … https://psnet.ahrq.gov/issue/assessing-system-failures-operating-rooms-and-intensive-care-units The … room to help organizations gain insight into system failures in those high-risk environments. … https://psnet.ahrq.gov/issue/assessing-system-failures-operating-rooms-and-intensive-care-units

93. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/862614/psn-pdf
    February 14, 2024 - Systemic failures in nursing home care--a scoping study. … Systemic failures in nursing home care—A scoping study. … https://psnet.ahrq.gov/issue/systemic-failures-nursing-home-care-scoping-study Nursing homes must balance … https://psnet.ahrq.gov/issue/systemic-failures-nursing-home-care-scoping-study https://psnet.ahrq.gov

94. Organizational Learning | PSNet
    psnet.ahrq.gov/curated-library/organizational-learning
    August 11, 2025 - Organizations are encouraged to learn from failures and sustain improvement. … High reliability organizations consistently examine and learn from failures. … High reliability organizations consistently examine and learn from failures. … Organizations are encouraged to learn from failures and sustain improvement. … , and recommend methods to minimize future failures.

95. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44873/psn-pdf
    March 21, 2016 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report … Communication failures are known to contribute to medical errors. … communication breakdowns led to patient harm, this report explores selected specialties where such failures … https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report

96. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/35585/psn-pdf
    March 28, 2011 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis … Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis … https://psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical … - incident The authors interviewed interns to understand communication failures with patient transfer … https://psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41778/psn-pdf
    January 18, 2013 - An observational study of the frequency, severity, and etiology of failures in postoperative care after … An observational study of the frequency, severity, and etiology of failures in postoperative care after … https://psnet.ahrq.gov/issue/observational-study-frequency-severity-and-etiology-failures-postoperative … - care-after-major This observational study at a large teaching hospital found that process failures … https://psnet.ahrq.gov/issue/observational-study-frequency-severity-and-etiology-failures-postoperative-care-after-major

98. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41541/psn-pdf
    September 26, 2012 - Failures in communication and information transfer across the surgical care pathway: interview study … Failures in communication and information transfer across the surgical care pathway: interview study … https://psnet.ahrq.gov/issue/failures-communication-and-information-transfer-across-surgical-care-pathway … - interview-study This qualitative study found considerable evidence for communication failures between … https://psnet.ahrq.gov/issue/failures-communication-and-information-transfer-across-surgical-care-pathway-interview-study

99. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46922/psn-pdf
    January 01, 2019 - Reducing interdisciplinary communication failures through secure text messaging: a quality improvement … Reducing Interdisciplinary Communication Failures Through Secure Text Messaging. … https://psnet.ahrq.gov/issue/reducing-interdisciplinary-communication-failures-through-secure-text- … messaging-quality Communication failures are a key contributor to preventable adverse events. … https://psnet.ahrq.gov/issue/reducing-interdisciplinary-communication-failures-through-secure-text-messaging-quality

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34884/psn-pdf
     August 03, 2009 - Communication failures: an insidious contributor to medical mishaps. … Communication failures: an insidious contributor to medical mishaps. … https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps In order to … Several anecdotes illustrate the role communication failures played in these mishaps and how common … https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps