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Showing results for "failures".

  1. 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

  2. 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://

  3. 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

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43809/psn-pdf
    February 25, 2015 - 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 … psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all- failures … The authors describe how systematically capturing small failures led to recognition of faulty processes … psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all-failures

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44767/psn-pdf
    January 20, 2016 - Applying psychological theory to understanding failures in modern healthcare settings. … Applying psychological theory to understanding failures in modern healthcare settings. … https://psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding- failures-modern … concepts from psychology, including theories related to behavior and cognition, to understand why care failures … https://psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40365/psn-pdf
    February 12, 2014 - https://psnet.ahrq.gov/issue/strategies-learning-failure Failures are inevitable in any industry, especially … 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 in … The author, who has extensively analyzed high- profile failures in many industries, recommends that

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41469/psn-pdf
    October 19, 2012 - Deconstructing intraoperative communication failures. … Deconstructing intraoperative communication failures. … https://psnet.ahrq.gov/issue/deconstructing-intraoperative-communication-failures Video recordings of … six complex surgical procedures revealed that communication failures were frequent, especially in discussions … https://psnet.ahrq.gov/issue/deconstructing-intraoperative-communication-failures https://psnet.ahrq.gov

  8. 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?

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73403/psn-pdf
    June 16, 2021 - Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas … https://psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville … https://psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville-arkansas-va … https://psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville-arkansas-va

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73416/psn-pdf
    June 23, 2021 - An observational study of postoperative handoff standardization failures. … An observational study of postoperative handoff standardization failures. … https://psnet.ahrq.gov/issue/observational-study-postoperative-handoff-standardization-failures Standardized … https://psnet.ahrq.gov/issue/observational-study-postoperative-handoff-standardization-failures https

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843321/psn-pdf
    February 01, 2023 - Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. … https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event … https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event-reach-patient … https://psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event-reach-patient

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849615/psn-pdf
    May 31, 2023 - Clinical Investigation Booking Systems Failures: Written Communications in Community Languages. … https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications- … https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-community-languages … https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-community-languages

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40464/psn-pdf
    June 10, 2018 - Multiple latent failures align to allow a serious drug interaction to harm a patient. … https://psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient … Detailing a case in which latent failures led to patient harm, this article encourages health care … providers investigating adverse events to consider how both active and latent failures may line up to … https://psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient

  14. Organizational Learning | PSNet

    psnet.ahrq.gov/curated-library/organizational-learning
    April 28, 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.

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36288/psn-pdf
    December 23, 2016 - Preventing adverse events caused by emergency electrical power system failures. … December 23, 2016 Preventing adverse events caused by emergency electrical power system failures. … https://psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system- failures … https://psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures … https://psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures

  16. 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

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42473/psn-pdf
    August 13, 2013 - Surgical technology and operating-room safety failures: a systematic review of quantitative studies. … Surgical technology and operating-room safety failures: a systematic review of quantitative studies. … https://psnet.ahrq.gov/issue/surgical-technology-and-operating-room-safety-failures-systematic-review … - quantitative-studies Surgical equipment failures have been implicated as a significant contributor … https://psnet.ahrq.gov/issue/surgical-technology-and-operating-room-safety-failures-systematic-review-quantitative-studies

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43436/psn-pdf
    August 13, 2014 - Decreasing handoff-related care failures in children's hospitals. … Decreasing handoff-related care failures in children's hospitals. … https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-failures-childrens-hospitals Discontinuity … 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

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40068/psn-pdf
    January 19, 2011 - Application of root cause analysis on malpractice claim files related to diagnostic failures. … Application of root cause analysis on malpractice claim files related to diagnostic failures. … //psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic- failures … https://psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic-failures … https://psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic-failures

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73637/psn-pdf
    August 25, 2021 - Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System … https://psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city … https://psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system … https://psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
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