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Showing results for "failures".

161. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36078/psn-pdf
     July 03, 2013 - Inquiry into reporter's death finds multiple failures in care. July 3, 2013 Stout D. … https://psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care This article reports … The investigation uncovered a range of failures in emergency care and is described in a report available … https://psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care

162. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34794/psn-pdf
     November 18, 2015 - The model discussed focuses on two types of failures, which share equal importance in analysis but distinguish … The first, active failures, consists of mistakes made by providers in the delivery of care. … The second, latent failures, represents flaws in the systems of care. … The authors use a case example in anesthesia to illustrate how searching for active failures alone fails … analysis of past disasters has offered a useful model to differentiate provider from organizational failures

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44179/psn-pdf
     November 20, 2015 - Routine failures in the process for blood testing and the communication of results to patients in primary … Routine failures in the process for blood testing and the communication of results to patients in primary … https://psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients … https://psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients-primary-care-uk … https://psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients-primary-care-uk

164. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37066/psn-pdf
     October 03, 2011 - Improving patient safety by identifying latent failures in successful operations. … Improving patient safety by identifying latent failures in successful operations. … https://psnet.ahrq.gov/issue/improving-patient-safety-identifying-latent-failures-successful-operations … https://psnet.ahrq.gov/issue/improving-patient-safety-identifying-latent-failures-successful-operations

165. 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

166. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34985/psn-pdf
     July 14, 2010 - The role of automation in complex system failures. July 14, 2010 Perry SJ, Wears RL, Cook RI. … The role of automation in complex system failures. J Patient Saf. 2005;1(1):56-61. … https://psnet.ahrq.gov/issue/role-automation-complex-system-failures The authors present a case of automation … https://psnet.ahrq.gov/issue/role-automation-complex-system-failures

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42501/psn-pdf
     January 07, 2015 - Syndromic surveillance for health information system failures: a feasibility study. … Syndromic surveillance for health information system failures: a feasibility study. … https://psnet.ahrq.gov/issue/syndromic-surveillance-health-information-system-failures-feasibility-study … https://psnet.ahrq.gov/issue/syndromic-surveillance-health-information-system-failures-feasibility-study

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37873/psn-pdf
     June 16, 2009 - Dropping the baton: a qualitative analysis of failures during the transition from emergency department … Dropping the baton: a qualitative analysis of failures during the transition from emergency department … https://psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency … https://psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient … https://psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient

169. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864864/psn-pdf
     March 20, 2024 - Systemic failures in health care oversight. March 20, 2024 Campbell JL. … https://psnet.ahrq.gov/issue/systemic-failures-health-care-oversight Questions exist as to why practitioners … https://psnet.ahrq.gov/issue/systemic-failures-health-care-oversight https://psnet.ahrq.gov/issue/retrievals-reveals-painful-experiences-female-patients-are-often-ignored

170. 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

171. 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

172. 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.

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41934/psn-pdf
     May 24, 2016 - Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on … https://psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures- … https://psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment … https://psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment

174. 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,

175. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41051/psn-pdf
     February 20, 2012 - What do patients and relatives know about problems and failures in care? … What do patients and relatives know about problems and failures in care? … https://psnet.ahrq.gov/issue/what-do-patients-and-relatives-know-about-problems-and-failures-care Interviews … https://psnet.ahrq.gov/issue/what-do-patients-and-relatives-know-about-problems-and-failures-care https

176. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44169/psn-pdf
     November 06, 2015 - Weak oversight allows lab failures to put patients at risk. November 6, 2015 Gabler E. … https://psnet.ahrq.gov/issue/weak-oversight-allows-lab-failures-put-patients-risk Reporting on weaknesses … methods, this news article discusses patients' experiences with testing errors to illustrate how such failures … https://psnet.ahrq.gov/issue/weak-oversight-allows-lab-failures-put-patients-risk https://psnet.ahrq.gov

177. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46286/psn-pdf
     September 13, 2017 - Preventing blood transfusion failures: FMEA, an effective assessment method. … Preventing blood transfusion failures: FMEA, an effective assessment method. … https://psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method … https://psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method https

178. Communication failures in the operating room: an observational classification of recurrent types and effects. | PSNet
     psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and
     April 06, 2011 - Study Classic Communication failures in the operating room … 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

179. Participating in a multisite study exploring operational failures encountered by frontline nurses: lessons learned. | PSNet
     psnet.ahrq.gov/issue/participating-multisite-study-exploring-operational-failures-encountered-frontline-nurses
     July 05, 2017 - Commentary Participating in a multisite study exploring operational failures encountered … 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 … Download Citation Related Resources From the Same Author(s) Operational failures

180. Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah. | PSNet
     psnet.ahrq.gov/issue/failures-care-coordination-and-reviewing-patients-death-va-salt-lake-city-healthcare-system
     April 19, 2023 - Book/Report Failures in Care Coordination and Reviewing a Patient's Death at the … Citation Text: Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City … Linkedin Copy URL Cite Citation Citation Text: Failures … August 2, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with