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psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons
April 03, 2013 - Study
Giving up learning from failures? … An examination of learning from one's own failures in the context of heart surgeons. … Giving up learning from failures? … An examination of learning from one's own failures in the context of heart surgeons. … Giving up learning from failures?
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psnet.ahrq.gov/issue/deconstructing-intraoperative-communication-failures
July 25, 2012 - Study
Deconstructing intraoperative communication failures. … Deconstructing intraoperative communication failures. … Video recordings of six complex surgical procedures revealed that communication failures were frequent … Deconstructing intraoperative communication failures.
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psnet.ahrq.gov/issue/automation-failures-and-patient-safety
November 21, 2012 - Review
Automation failures and patient safety. … Automation failures and patient safety. … This review examines automation failures in anesthesiology. … Automation failures and patient safety. … The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Annual Perspective
Impact of System Failures on Healthcare Workers
George Zangaro, PhD, RN, … Impact of System Failures on Healthcare Workers . PSNet [internet]. … Impact of System Failures on Healthcare Workers . PSNet [internet]. … Impact of System Failures on Healthcare Workers
Healthcare workers deliver care as part of complex … Impact of System Failures on Healthcare Workers . PSNet [internet].
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psnet.ahrq.gov/issue/mistakes-errors-and-failures-across-cultures-navigating-potentials
January 20, 2021 - Book/Report
Mistakes, Errors and Failures across Cultures. … Citation Text:
Mistakes, Errors and Failures across Cultures. Vanderheiden E, Mayer C, eds. … URL
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Mistakes, Errors and Failures
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psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors
November 01, 2012 - Study
Reconciliation failures lead to medication errors. … Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9. … Reconciliation failures lead to medication errors.
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psnet.ahrq.gov/issue/systemic-failures-health-care-oversight
July 05, 2006 - Commentary
Systemic failures in health care oversight. … Citation Text:
Systemic failures in health care oversight. Campbell JL. … Copy URL
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Systemic failures
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psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing
November 03, 2021 - Study
Operational failures and interruptions in hospital nursing. … Operational failures and interruptions in 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 … Operational failures and interruptions in hospital nursing.
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psnet.ahrq.gov/issue/role-automation-complex-system-failures
June 28, 2013 - Commentary
The role of automation in complex system failures. … The role of automation in complex system failures. … The role of automation in complex system failures.
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psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis
January 06, 2017 - Study
Process of care failures in breast cancer diagnosis. … Process of care failures in breast cancer diagnosis. … cases of recently diagnosed breast cancer to identify patient- and provider-related process of care failures … delay of at least 90 days occurred between symptom onset and diagnosis and found a high rate of process failures … Process of care failures in breast cancer diagnosis.
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psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps
February 24, 2011 - Study
Classic
Communication failures: an insidious contributor … Communication failures: an insidious contributor to medical mishaps. … In order to better understand the impact of communication failures, this qualitative study analyzed interview … Several anecdotes illustrate the role communication failures played in these mishaps and how common these … Communication failures: an insidious contributor to medical mishaps.
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psnet.ahrq.gov/issue/failures-respectful-care-critically-ill-patients
December 19, 2018 - Study
Failures in the respectful care of critically ill patients. … Failures in the Respectful Care of Critically Ill Patients. … Failures in the Respectful Care of Critically Ill Patients.
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psnet.ahrq.gov/issue/observational-study-postoperative-handoff-standardization-failures
March 10, 2021 - Study
An observational study of postoperative handoff standardization failures. … An observational study of postoperative handoff standardization failures. … An observational study of postoperative handoff standardization failures.
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures
Citation Text:
Mieu H, Olson KA. … Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. … Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. … Ha, DO, and Kristin Alexis Olson, MD In this case, a confluence of individual decisions and system failures … Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet].
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psnet.ahrq.gov/issue/operational-failures-detected-frontline-acute-care-nurses
July 19, 2023 - Study
Operational failures detected by frontline acute care nurses. … Operational Failures Detected by Frontline Acute Care Nurses. … This prospective reporting study asked frontline nurse participants to record operational failures, … Nurses recorded about six such failures per shift, suggesting that systems failures are common in acute … Operational Failures Detected by Frontline Acute Care Nurses.
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psnet.ahrq.gov/issue/strategies-learning-failure
September 25, 2024 - Failures are inevitable in any industry, especially in one as complex as health care. … The ability to learn from failures is a crucial characteristic of high reliability organizations , and … This article draws a distinction between preventable failures in predictable operations—which are largely … due to slips , and can be prevented by interventions such as checklists —and unavoidable failures … staff, and promote experimentation and creative problem-solving in order to minimize the stigma of failures
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psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care
March 30, 2016 - Newspaper/Magazine Article
Inquiry into reporter's death finds multiple failures … Citation Text:
Inquiry into reporter's death finds multiple failures in care. Stout D. … The investigation uncovered a range of failures in emergency care and is described in a report available … Cite
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Inquiry into reporter's death finds multiple failures
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psnet.ahrq.gov/issue/decreasing-handoff-related-care-failures-childrens-hospitals
April 24, 2018 - Study
Decreasing handoff-related care failures in children's hospitals. … Decreasing handoff-related care failures in children's hospitals. … Following introduction of a structured handoff tool , handoff-related care failures declined and provider … Handoff-related care failures were defined as insufficient information transfer that affected the patient … Decreasing handoff-related care failures in children's hospitals.
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psnet.ahrq.gov/issue/impacts-operational-failures-primary-care-physicians-work-critical-interpretive-synthesis
May 22, 2024 - Review
Impacts of operational failures on primary care physicians' work: a critical … Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis of … This review synthesized research exploring how operational failures (e.g., distractions , situational … The authors suggest that future research focus on which operational failures have the highest impact … Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis of
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psnet.ahrq.gov/issue/weak-oversight-allows-lab-failures-put-patients-risk
June 12, 2019 - Newspaper/Magazine Article
Weak oversight allows lab failures to put patients at … Citation Text:
Weak oversight allows lab failures to put patients at risk. Gabler E. … methods, this news article discusses patients' experiences with testing errors to illustrate how such failures … Cite
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Weak oversight allows lab failures