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Showing results for "failures".

  1. 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

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. | PSNet

    psnet.ahrq.gov/issue/care-and-oversight-deficiencies-related-multiple-homicides-louis-johnson-va-medical-center
    February 10, 2021 - Health care system failures can enable unrecognized, persistent criminal behavior. … May 1, 2015 Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … May 3, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

  9. Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona. | PSNet

    psnet.ahrq.gov/issue/deficiencies-quality-management-processes-and-delays-communication-test-results-and-follow
    March 01, 2023 - Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … April 26, 2006 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … Improving Diagnostic Safety and Quality April 26, 2023 Multiple Failures

  10. 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

  11. 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

  12. Syndromic surveillance for health information system failures: a feasibility study. | PSNet

    psnet.ahrq.gov/issue/syndromic-surveillance-health-information-system-failures-feasibility-study
    November 03, 2015 - Study Syndromic surveillance for health information system failures: a feasibility … Syndromic surveillance for health information system failures: a feasibility study. … Syndromic surveillance for health information system failures: a feasibility study. … November 2, 2010 A systematic review of failures in handoff communication during intrahospital

  13. Trainees' perceptions of patient safety practices: recounting failures of supervision. | PSNet

    psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision
    September 20, 2011 - Study Trainees' perceptions of patient safety practices: recounting failures of supervision … Trainees' perceptions of patient safety practices: recounting failures of supervision. … Trainees' perceptions of patient safety practices: recounting failures of supervision.

  14. 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

  15. 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

  16. 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

  17. 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

  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/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

  20. Improving patient safety by identifying latent failures in successful operations. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-identifying-latent-failures-successful-operations
    September 15, 2010 - Study Improving patient safety by identifying latent failures in successful operations … Improving patient safety by identifying latent failures in successful operations. … Improving patient safety by identifying latent failures in successful operations.
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