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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40473/psn-pdf
    July 02, 2011 - A systematic review of failures in handoff communication during intrahospital transfers. … A systematic review of failures in handoff communication during intrahospital transfers. … https://psnet.ahrq.gov/issue/systematic-review-failures-handoff-communication-during-intrahospital- … transfers Communication failures at the time of patient handoffs have been frequently implicated in … https://psnet.ahrq.gov/issue/systematic-review-failures-handoff-communication-during-intrahospital-transfers

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38621/psn-pdf
    February 18, 2011 - Process of care failures in breast cancer diagnosis. … Process of care failures in breast cancer diagnosis. … https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis Diagnostic errors have been … cases of recently diagnosed breast cancer to identify patient- and provider-related process of care failures … https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis https://psnet.ahrq.gov/issue

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36530/psn-pdf
    January 07, 2011 - Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. … Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. … psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and- attentional-failures … extended shifts were much more likely to report both significant preventable errors and attentional failures … /psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures

  4. 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

  5. Taxonomic Guidance for Remedial Actions (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
    December 23, 2004 - Technical problems (machine failures) 2. Organizational problems 3. … Human performance failures 4. … Of the organizational failures, those easiest to fix (training, and then protocols) come first. … This taxonomy addresses failures in health care settings. … refer to failures in the performance of fine motor skills, and tripping refers to failures in whole

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47427/psn-pdf
    June 19, 2019 - Failures in the respectful care of critically ill patients. … Failures in the Respectful Care of Critically Ill Patients. … https://psnet.ahrq.gov/issue/failures-respectful-care-critically-ill-patients Emotional and psychological … https://psnet.ahrq.gov/issue/failures-respectful-care-critically-ill-patients https://psnet.ahrq.gov/

  7. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. | PSNet

    psnet.ahrq.gov/issue/mortality-and-morbidity-rounds-mmr-pathology-relative-contribution-cognitive-bias-vs-systems
    May 18, 2022 - Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures … October 19, 2022 Effect of reducing interns' weekly work hours on sleep and attentional failures

  8. Learn-From-Defects-Facilitator-Guide (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - 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.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44141/psn-pdf
    November 06, 2015 - Failures in communication through documents and documentation across the perioperative pathway. … Failures in communication through documents and documentation across the perioperative pathway. … https://psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across- perioperative-pathway … https://psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across-perioperative-pathway … https://psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across-perioperative-pathway

  10. Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments. | PSNet

    psnet.ahrq.gov/issue/applicability-healthcare-failure-mode-and-effects-analysis-healthcare-epidemiology-evaluation
    October 19, 2022 - The mapped-out process then leads to identification of potential failures and the development of strategies … September 23, 2020 View More Related Resources Reducing failures … October 6, 2011 Assessing system failures in operating rooms and intensive care units … Use of failure mode and effects analysis for proactive identification of communication and handoff failures

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45912/psn-pdf
    May 09, 2017 - Medication reconciliation failures in children and young adults with chronic disease during intensive … Medication reconciliation failures in children and young adults with chronic disease during intensive … https://psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease … https://psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease-during-intensive … https://psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease-during-intensive

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45797/psn-pdf
    October 31, 2017 - Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures. … Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures. … https://psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care- failures … https://psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care-failures … https://psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care-failures

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34839/psn-pdf
    April 06, 2011 - Communication failures in the operating room: an observational classification of recurrent types and … Communication failures in the operating room: an observational classification of recurrent types and … https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent … https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and … https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45599/psn-pdf
    July 02, 2017 - Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency … Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency … https://psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care … https://psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care-emergency-and … https://psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care-emergency-and

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43093/psn-pdf
    August 12, 2014 - Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident … Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident … https://psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national … https://psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report … https://psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33931/psn-pdf
    June 23, 2015 - An analysis of major errors and equipment failures in anesthesia management: considerations for prevention … An analysis of major errors and equipment failures in anesthesia management: considerations for prevention … https://psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management- considerations-prevention … https://psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management-considerations-prevention … https://psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management-considerations-prevention

  17. Hand Hygiene Observational Audit Tracking Tool (xls file)

    www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
    December 01, 2021 - per Assessment for Job: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 Month … per Assessment for Job: Average # Failures per Audit - - - - - - - - - - #N/A … per Assessment for Location: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 … per Assessment for Location: Average # Failures per Audit - - - - - - - - - - … Skin is intact without open wounds or rashes # Failures

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. … Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. … https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March … Impact of System Failures on Healthcare Workers https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers … Organizations can adopt a systematic approach to gather and analyze data, identify system failures,

  19. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/865308
    January 01, 2024 - Failures are inevitable in any industry, especially in one as complex as health care. … 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.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47059/psn-pdf
    May 16, 2018 - Participating in a multisite study exploring operational failures encountered by frontline nurses: lessons … Participating in a Multisite Study Exploring Operational Failures Encountered by Frontline Nurses: Lessons … https://psnet.ahrq.gov/issue/participating-multisite-study-exploring-operational-failures-encountered … https://psnet.ahrq.gov/issue/participating-multisite-study-exploring-operational-failures-encountered-frontline-nurses … https://psnet.ahrq.gov/issue/participating-multisite-study-exploring-operational-failures-encountered-frontline-nurses
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