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Showing results for "failures".

  1. 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,

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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.

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72865/psn-pdf
    March 17, 2021 - We can learn from our failures. March 17, 2021 Zeynep Tufekci. The Atlantic. … February 26, 2021 https://psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures … Failures in communication have impacts on patients, teams, organizations and society. … https://psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures https://

  14. 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

  15. 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

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46139/psn-pdf
    September 23, 2017 - Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration … Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration … https://psnet.ahrq.gov/issue/impact-interruptions-distractions-and-cognitive-load-procedure-failures-and … https://psnet.ahrq.gov/issue/impact-interruptions-distractions-and-cognitive-load-procedure-failures-and-medication … https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing https://psnet.ahrq.gov

  17. 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

  18. A 60-year-old man with delayed care for a renal mass. | PSNet

    psnet.ahrq.gov/issue/60-year-old-man-delayed-care-renal-mass
    January 31, 2024 - This article discusses a patient who experienced delays in care due to a myriad of system failures in … The invited discussant explores the causes of these failures and discusses situational awareness , improved … The fact that JAMA chose a clinical scenario focusing on systems failures mirrors past efforts in the … 24, 2011 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34073/psn-pdf
    February 17, 2011 - Effect of reducing interns' weekly work hours on sleep and attentional failures. … Effect of reducing interns' weekly work hours on sleep and attentional failures. … https://psnet.ahrq.gov/issue/effect-reducing-interns-weekly-work-hours-sleep-and-attentional-failures … that limiting intern work hours to less than 80 hours per week led to more sleep and less attentional failures … https://psnet.ahrq.gov/issue/effect-reducing-interns-weekly-work-hours-sleep-and-attentional-failures

  20. Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room. | PSNet

    psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all-failures
    October 07, 2013 - Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in … The authors describe how systematically capturing small failures led to recognition of faulty processes … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in
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