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Showing results for "failures".

161. 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

162. Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation. | PSNet
     psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect-analysis-combined
     August 10, 2022 - Study Reducing failures in daily medical practice: healthcare failure mode and effect … Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with

163. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     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.

164. Failures in communication through documents and documentation across the perioperative pathway. | PSNet
     psnet.ahrq.gov/issue/failures-communication-through-documents-and-documentation-across-perioperative-pathway
     August 07, 2013 - Study Failures in communication through documents and documentation across the perioperative … Failures in communication through documents and documentation across the perioperative pathway. … Failures in communication through documents and documentation across the perioperative pathway. … and Quality April 26, 2023 Using incident reports to assess communication failures

165. 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

166. 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

167. A systems approach to analyzing and preventing hospital adverse events. | PSNet
     psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events
     March 30, 2022 - approach is based on the principle that accidents are not only the result of individual system component failures … Evolution of Root Cause Analysis February 26, 2025 Giving up learning from failures … An examination of learning from one's own failures in the context of heart surgeons. … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures

168. 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

169. 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

170. 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

171. 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

172. 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

173. Diagnostic Safety as a Challenge for Healthcare Leadership | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-1.html
     June 01, 2021 - and contribute to death for up to 80,000 patients in U.S. hospitals annually. 1 Evidence suggests failures … Location and Impact of Diagnostic Failures Balogh EP, Miller BT, Ball JR, eds. … Accessed June 1, 2021. 2015 CRICO Strategies National CBS Report: Malpractice Risks in Communication Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47045/psn-pdf
     January 21, 2019 - Information management goals and process failures during home visits for middle-aged and older adults … Information management goals and process failures during home visits for middle-aged and older adults … https://psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits- middle-aged-and-older … https://psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits-middle-aged-and-older … https://psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits-middle-aged-and-older

175. 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

176. An evaluation of information transfer through the continuum of surgical care: a feasibility study. | PSNet
     psnet.ahrq.gov/issue/evaluation-information-transfer-through-continuum-surgical-care-feasibility-study
     December 21, 2014 - Communication failures are common in surgical care. … August 11, 2010 Failures in communication and information transfer across the surgical … February 9, 2011 An observational study of the frequency, severity, and etiology of failures … July 6, 2012 Surgical technology and operating-room safety failures: a systematic review

177. 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

178. Sensemakingnotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
     June 02, 2025 - Active failures are also called human error. … Active failures are categorized in three main types: skill-based, rule-based, and knowledge-based. · … Latent conditions are sorted into two categories: technical failures and organizational failures. … 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.

179. 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

180. 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