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Showing results for "failures".

81. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. | PSNet
    psnet.ahrq.gov/issue/evaluation-preoperative-checklist-and-team-briefing-among-surgeons-nurses-and
    August 28, 2013 - a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures … a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures … Structured communication tools are being used increasingly to prevent critical communication failures … a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures … August 28, 2013 Using trainee failures to enhance learning: a qualitative study of pediatric

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. Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. | PSNet
    psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital
    June 22, 2017 - Study Using failure mode and effect analysis to identify potential failures in a … Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … this study, FMEA was used in a psychiatric hospital emergency department (ED) to identify potential failures … Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency

84. 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

85. 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

86. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. | PSNet
    psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures
    February 02, 2011 - Impact of extended-duration shifts on medical errors, adverse events, and attentional failures … Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. … extended shifts were much more likely to report both significant preventable errors and attentional failures … Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. … January 10, 2017 Effect of reducing interns' weekly work hours on sleep and attentional failures

87. Surgical technology and operating-room safety failures: a systematic review of quantitative studies. | PSNet
    psnet.ahrq.gov/issue/surgical-technology-and-operating-room-safety-failures-systematic-review-quantitative-studies
    May 06, 2015 - Review Surgical technology and operating-room safety failures: a systematic review … Surgical technology and operating-room safety failures: a systematic review of quantitative studies. … Surgical equipment failures have been implicated as a significant contributor to errors and delays … Surgical technology and operating-room safety failures: a systematic review of quantitative studies. … October 19, 2022 An observational study of the frequency, severity, and etiology of failures

88. Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. | PSNet
    psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville-arkansas-va
    July 14, 2021 - Book/Report Pathology Oversight Failures at the Veterans Health Care System of the … Citation Text: Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville … URL Cite Citation Citation Text: Pathology Oversight Failures … July 26, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … February 10, 2021 Failures in Care Coordination and Reviewing a Patient's Death at the

89. 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

90. 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,

91. 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

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. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. | PSNet
    psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident
    April 16, 2008 - Study Communication failures in patient sign-out and suggestions for improvement: … Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis … The authors interviewed interns to understand communication failures with patient transfer processes. … Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

94. 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

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/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

97. 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

98. Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure. | PSNet
    psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists-allowing
    December 14, 2022 - Study Using trainee failures to enhance learning: a qualitative study of pediatric … 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

99. 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

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47045/psn-pdf
     January 21, 2019 - Information management goals and process failures during home visits for middle-aged and older adults … Information management goals and process failures during home visits for middle-aged and older adults … https://psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits- middle-aged-and-older … https://psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits-middle-aged-and-older … https://psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits-middle-aged-and-older