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Showing results for "failures".

1. Learning From Defects | Agency for Healthcare Research and Quality
   www.ahrq.gov/hai/tools/mrsa-prevention/surgery/learning-from-defects.html
   April 01, 2025 - Every system, no matter how well designed, will include failures. … Identifying these failures allows us to address and fix a defect. … Guide (DOCX, 5 MB) Presentation: Learning From Defects: Applying the Swiss Cheese Model of System Failures … Documents: Learning From Defects: Applying the Swiss Cheese Model of System Failures – Slides (PPTX … , 5 MB) Learning From Defects: Applying the Swiss Cheese Model of System Failures - Facilitator Guide

2. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
   April 07, 2008 - Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures … Process failures were analyzed for likelihood, severity, and discoverability of occurrence using the … , such as poor logistics, equipment failures, and poor policies/procedures (Table 3). … Four of the failure modes were active failures. … However, despite this knowledge, many process flaws and team failures were identified.

3. PowerPoint Presentation
   www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
   June 01, 2021 - an opportunity to prevent the same problem from occurring again System design Can result in “latent” failures … Human behavior Can result in “active” failures 3 Changing the System 3 System Failures System failures … Errors that occur because of individual actions Generally readily apparent Examples of active failures … Organizational Influences – Latent failures Unsafe acts – Active failures Unsafe supervision – Latent … 17 Changing the System 17 Review Consider system/active failures which may have led to the problem

4. PowerPoint Presentation
   www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/131-ss-swiss-cheese.pptx
   April 01, 2025 - PowerPoint Presentation Learning From Defects: Applying the “Swiss Cheese Model” of System Failures … Apply a patient example to discover system failures. … : Swiss Cheese Model1 active failure latent failures Adapted from: Reason, J. … include latent and active failures. … The impact of operational failures on hospital nurses and their patients.

5. TeamSTEPPS® Diagnosis Improvement: Infographic (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/dxsafety-infographic.pdf
   February 01, 2022 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … patients experiences a diagnostic error firsthand.11 in 3 Diagnostic-related communication failures … 2012.pdf https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

6. TeamSTEPPS® Diagnosis Improvement: Infographic (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-infographic.pdf
   February 01, 2022 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … patients experiences a diagnostic error firsthand.11 in 3 Diagnostic-related communication failures … 2012.pdf https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

7. 130-Ss-Swiss-Cheese-Fg (doc file)
   www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
   April 01, 2025 - To ensure a defect never happens again, failures should be viewed from a systems lens to improve the … the “Swiss cheese model” to illustrate how system failures occur and why some failures lead to an event … Active failures occur when an “operator” performs an unsafe action that leads to an event. … active failures. … In other words, active failures are the adverse events the team thinks about and attempts to avoid.

8. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
   www.ahrq.gov/patient-safety/resources/liability/baker.html
   August 01, 2017 - Type of event seemed to affect what failures clinicians indicated should be disclosed, while type of … event had little effect on what failures patients and family members indicated should be disclosed. … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … We then examined the failures across events to create a common set of failures by the phases of the L … to the clinician rankings of the same failures.

9. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
   www.ahrq.gov/patient-safety/reports/liability/baker.html
   August 01, 2017 - Type of event seemed to affect what failures clinicians indicated should be disclosed, while type of … event had little effect on what failures patients and family members indicated should be disclosed. … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … We then examined the failures across events to create a common set of failures by the phases of the L … to the clinician rankings of the same failures.

10. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
    January 01, 2003 - Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities … 395 Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care … models provide contextual maps of the errors and behaviors that lead to medication delivery system failures … Risk modeling teams then identify the failures that link together, leading to the top-level event. … The models provide contextual maps of the errors and behaviors that lead to system failures so that

11. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

12. Changing-System-Facilitator-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - These result in latent failures. … These result in active failures. … Slide 3 System Failures SAY: System failures are considered latent problems. … Slide 4 Active Failures SAY: Active failures occur because of human error. … Does the problem you are addressing involve latent failures, active failures, or both?

13. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

14. The Science of Safety:​ Principles in Practice | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mrsa-prevention/surgery/science-of-safety.html
    April 01, 2025 - Guide (DOCX, 9 MB) Presentation: Learning From Defects: Applying the Swiss Cheese Model of System Failures … defect Review the “Swiss cheese model” of system failure Apply a patient example to discover system failures … Documents: Learning From Defects: Applying the Swiss Cheese Model of System Failures – Slides (PPTX … , 5 MB) Learning From Defects: Applying the Swiss Cheese Model of System Failures - Facilitator Guide

15. Taxonomic Guidance for Remedial Actions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
    December 23, 2004 - Technical problems (machine failures) 2. Organizational problems 3. … Human performance failures 4. … Of the organizational failures, those easiest to fix (training, and then protocols) come first. … This taxonomy addresses failures in health care settings. … refer to failures in the performance of fine motor skills, and tripping refers to failures in whole

16. Hand Hygiene Observational Audit Tracking Tool (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool.xlsx
    June 01, 2021 - per Assessment for Job: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 Month … per Assessment for Job: Average # Failures per Audit - - - - - - - - - - #N/A … per Assessment for Location: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 … per Assessment for Location: Average # Failures per Audit - - - - - - - - - - … Skin is intact without open wounds or rashes # Failures

17. Hand Hygiene Observational Audit Tracking Tool (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
    December 01, 2021 - per Assessment for Job: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 Month … per Assessment for Job: Average # Failures per Audit - - - - - - - - - - #N/A … per Assessment for Location: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 … per Assessment for Location: Average # Failures per Audit - - - - - - - - - - … Skin is intact without open wounds or rashes # Failures

18. Diagnostic Safety as a Challenge for Healthcare Leadership | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/leadership-1.html
    June 01, 2021 - and contribute to death for up to 80,000 patients in U.S. hospitals annually. 1 Evidence suggests failures … Location and Impact of Diagnostic Failures Balogh EP, Miller BT, Ball JR, eds. … Accessed June 1, 2021. 2015 CRICO Strategies National CBS Report: Malpractice Risks in Communication Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

19. Diagnostic Safety as a Challenge for Healthcare Leadership | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-1.html
    June 01, 2021 - and contribute to death for up to 80,000 patients in U.S. hospitals annually. 1 Evidence suggests failures … Location and Impact of Diagnostic Failures Balogh EP, Miller BT, Ball JR, eds. … Accessed June 1, 2021. 2015 CRICO Strategies National CBS Report: Malpractice Risks in Communication Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

20. Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
    June 01, 2023 - experiences, explores: How patient-reported experiences can augment other methods of identifying diagnostic failures … Feedback from patient experiences can be useful for addressing diagnostic failures in two distinct ways