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psnet.ahrq.gov/issue/patient-safety-attitudes-and-behaviors-graduating-medical-students
June 01, 2016 - November 16, 2022
Decreasing handoff-related care failures in children's hospitals. … October 31, 2018
Trainees' perceptions of patient safety practices: recounting failures
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psnet.ahrq.gov/issue/introducing-safety-score-audit-staff-member-and-patient-safety
April 16, 2014 - April 16, 2014
Operational failures in general practice: a consensus-building study on … August 20, 2018
Impacts of operational failures on primary care physicians' work: a critical
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psnet.ahrq.gov/issue/team-communication-during-patient-handover-operating-room-more-facts-and-figures
December 16, 2009 - April 3, 2013
Deconstructing intraoperative communication failures. … Use of failure mode and effects analysis for proactive identification of communication and handoff failures
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psnet.ahrq.gov/issue/nexus-nursing-leadership-and-culture-safer-patient-care
January 18, 2018 - September 3, 2011
Operational failures detected by frontline acute care nurses. … October 4, 2017
Failures in communication through documents and documentation across
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psnet.ahrq.gov/issue/patient-safety-otolaryngology-descriptive-review
July 14, 2010 - January 14, 2014
Surgical technology and operating-room safety failures: a systematic … August 13, 2013
Deconstructing intraoperative communication failures.
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psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
June 21, 2016 - November 12, 2014
Decreasing handoff-related care failures in children's hospitals. … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures
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psnet.ahrq.gov/issue/usability-and-feasibility-consumer-facing-technology-reduce-unsafe-medication-use-older
February 17, 2011 - Same Author(s)
Effect of reducing interns' weekly work hours on sleep and attentional failures … March 6, 2019
Multiple latent failures align to allow a serious drug interaction to harm
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psnet.ahrq.gov/issue/nurses-perceived-skills-and-attitudes-about-updated-safety-concepts-impact-medication
January 03, 2017 - September 27, 2017
Impact of interruptions, distractions, and cognitive load on procedure failures … July 2, 2014
Identifying the latent failures underpinning medication administration errors
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psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis
July 13, 2010 - June 23, 2009
Communication failures contributing to patient injury in anaesthesia malpractice … September 21, 2022
Communication failures contributing to patient injury in anaesthesia
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psnet.ahrq.gov/issue/provider-perspectives-partnering-parents-hospitalized-children-improve-safety
November 30, 2016 - November 30, 2016
Operational failures detected by frontline acute care nurses. … July 5, 2017
Participating in a multisite study exploring operational failures encountered
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psnet.ahrq.gov/issue/checking-lists-systematic-review-electronic-checklist-use-health-care
August 08, 2018 - Related Resources From the Same Author(s)
Identification and characterization of failures … July 17, 2019
Reducing interdisciplinary communication failures through secure text messaging
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psnet.ahrq.gov/issue/safety-through-redundancy-case-study-hospital-patient-transfers
November 03, 2015 - November 3, 2015
Syndromic surveillance for health information system failures: a feasibility … December 21, 2014
A systematic review of failures in handoff communication during intrahospital
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psnet.ahrq.gov/issue/automated-identification-extreme-risk-events-clinical-incident-reports
November 03, 2015 - November 3, 2015
Syndromic surveillance for health information system failures: a feasibility … November 2, 2010
A systematic review of failures in handoff communication during intrahospital
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psnet.ahrq.gov/issue/last-orders-follow-tests-ordered-day-hospital-discharge
November 03, 2015 - November 3, 2015
Syndromic surveillance for health information system failures: a feasibility … November 2, 2010
A systematic review of failures in handoff communication during intrahospital
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psnet.ahrq.gov/issue/factors-influencing-perioperative-nurses-error-reporting-preferences
June 23, 2010 - December 8, 2010
Communication failures in the operating room: an observational classification … August 14, 2019
Using incident reports to assess communication failures and patient outcomes
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psnet.ahrq.gov/issue/quality-care-cranial-implant-surgeries-james-haley-va-medical-center-tampa-florida
June 13, 2012 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … July 27, 2022
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with
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psnet.ahrq.gov/issue/practical-challenges-introducing-who-surgical-checklist-uk-pilot-experience
September 26, 2012 - RIS
Download Citation
Related Resources From the Same Author(s)
Failures … May 6, 2015
An observational study of the frequency, severity, and etiology of failures
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - medication errors
Describe a model for a systems approach to error analysis
Identify weaknesses or failures … Approach to Medication Errors
The goal of a systems-based analysis of errors is to identify system failures … errors should use the ISMP model (see slide 10)
Applying the framework to this case reveals numerous failures … id=51
20
This Case
This case highlights the multiple systems failures.
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psnet.ahrq.gov/node/49688/psn-pdf
August 21, 2013 - This commentary will
review key factors that hinder communication, the implications of failures in this … adverse events and unnecessary health care resource
utilization.(1-3)
Unfortunately, communication failures … these patient populations and some evidence suggests similar
patterns.(6)
The origin of communication failures … In the featured case, it is evident that many of these factors played a role in the communication failures … verbal interactions were inadequate and, therefore, failed to uncover or address
existing communication failures
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psnet.ahrq.gov/issue/risks-complications-attending-physicians-after-performing-nighttime-procedures
February 14, 2018 - July 10, 2008
Effect of reducing interns' weekly work hours on sleep and attentional failures … September 21, 2022
Communication failures contributing to patient injury in anaesthesia