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Showing results for "failures".

101. 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

102. 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

103. 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

104. 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

105. 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

106. 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

107. Fault Tree Analysis | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fault-tree-analysis
     January 01, 2023 - Acronym FTA Description Fault tree analyses (FTAs) study specific system, process, or product failures … ANALYZE THE TREE to understand how the causes are interrelated and think of how to prevent failures. … Pay closest attention to failures that are the most likely to happen. … Useful for modeling team-based failures.

108. 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

109. 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

110. 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

111. 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

112. 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

113. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854264/psn-pdf
     October 04, 2023 - Patient death tied to lack of proper escalation process for barcode scanning failures. … https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures … solution availability and staffing improvements are discussed to minimize opportunities for the systemic failures … https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures

114. 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

115. 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

116. "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.

117. Failure to debrief after critical events in anesthesia is associated with failures in communication during the event. | PSNet
     psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures-communication-during
     September 24, 2018 - Emerging Classic Failure to debrief after critical events in anesthesia is associated with failures … Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during … Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures … Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during

118. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35174/psn-pdf
     June 23, 2009 - Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign … Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures to Detect the Foreign … https://psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures … case report, the authors discuss a series of errors and illustrate the concepts of active and latent failures … https://psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures-detect-foreign

119. 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.

120. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34861/psn-pdf
     November 11, 2015 - When things go wrong: how health care organizations deal with major failures. … When things go wrong: how health care organizations deal with major failures. … https://psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures … The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the … https://psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures https