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Showing results for "failures".

  1. 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

  2. Final Progress Report: Sociotechnical Probabilistic Risk Assessment in Home Health Care (pdf file)

    www.ahrq.gov/sites/default/files/2025-02/silver2-report.pdf
    January 01, 2025 - , and combinations of failures, required for the occurrence of ACH. …  care plan execution failures  patient monitoring failures 6 ST-PRA IN HOME HEALTH CARE • Structured … It used a systems perspective to classify the nature of failures identified. … None have processes for systematically identifying and learning from such failures. 3. … The nature of the performance failures provides even greater insights.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44876/psn-pdf
    February 10, 2016 - The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures … psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors- system-failures … psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors-system-failures … psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors-system-failures

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35802/psn-pdf
    January 02, 2017 - Reconciliation failures lead to medication errors. January 2, 2017 Santell JP. … Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9. … https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors Medication reconciliation … https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors https://psnet.ahrq.gov/primer

  5. Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. | PSNet

    psnet.ahrq.gov/issue/latent-and-active-failures-perfectly-align-allow-preventable-adverse-event-reach-patient
    March 14, 2023 - Newspaper/Magazine Article Latent and active failures perfectly align to allow a … Citation Text: Latent and active failures perfectly align to allow a preventable adverse event to reach … Copy URL Cite Citation Citation Text: Latent and active failures

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73426/psn-pdf
    June 23, 2021 - The majority of preventable adverse events are multifactorial in nature and are a result of system failures … Failures include differences in recording electronic health record notes and communication between providers … Investigations of all adverse events will help identify and correct system failures to improve patient

  7. 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

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837975/psn-pdf
    August 31, 2022 - These events primarily involved communication failures, poor teamwork, and situational awareness failures … psnet.ahrq.gov/issue/application-aviation-black-box-principle-pediatric-cardiac-surgery-tracking-all-failures

  9. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
    January 01, 2024 - Moderate number of failures. Low Low likelihood that current controls will detect. … High number of failures likely. … High number of failures likely. … Very high number of failures likely. … History of failures.

  10. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. | PSNet

    psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management-considerations-prevention
    May 27, 2011 - Study Classic An analysis of major errors and equipment failures … 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 … Related Resources An observational study of postoperative handoff standardization failures

  11. Failure Mode and Effects Analysis | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fmea-analysis
    January 01, 2023 - Description Failure mode and effects analysis (FMEA) is a method that attempts to identify all possible failures … When examining failures. How do I use this tool? 1. ASSEMBLE A CROSS-FUNCTIONAL TEAM. … These are controls in place to prevent failures from getting to the patient. … These values will aid you when ranking the order to address potential failures. 13.

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39729/psn-pdf
    September 20, 2011 - Contextual errors and failures in individualizing patient care: a multicenter study. … Contextual errors and failures in individualizing patient care: a multicenter study. … https://psnet.ahrq.gov/issue/contextual-errors-and-failures-individualizing-patient-care-multicenter-study … https://psnet.ahrq.gov/issue/contextual-errors-and-failures-individualizing-patient-care-multicenter-study

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37425/psn-pdf
    March 28, 2012 - Frequency and outcome of cervical cancer prevention failures in the United States. … Frequency and outcome of cervical cancer prevention failures in the United States. … https://psnet.ahrq.gov/issue/frequency-and-outcome-cervical-cancer-prevention-failures-united-states … https://psnet.ahrq.gov/issue/frequency-and-outcome-cervical-cancer-prevention-failures-united-states

  14. 2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process. | PSNet

    psnet.ahrq.gov/issue/2014-annual-benchmarking-report-malpractice-risks-diagnostic-process
    September 26, 2012 - The authors use the data to explore cognitive and process failures that contributed to diagnostic … June 24, 2020 Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report … March 21, 2016 Malpractice Risks in Communication Failures: 2015 Annual Benchmarking

  15. Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. | PSNet

    psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and-care-patient-chico-community-based-outpatient
    November 29, 2023 - This report examines organizational failures in responding to staff and clinical leaders’ concerns … 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

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49475/psn-pdf
    March 01, 2005 - By preventing these sorts of failures, IT applications reduce the need for such workarounds. … Indeed, preventing such failures is one reason that IT is now being deployed. … - based failures are infrequent but potentially severe. … Defenses against these failures are more difficult to devise and less likely to be robust.(11) More … Although failures involving IT are often regarded as human (operator) error, these failures actually

  17. A systematic quantitative assessment of risks associated with poor communication in surgical care. | PSNet

    psnet.ahrq.gov/issue/systematic-quantitative-assessment-risks-associated-poor-communication-surgical-care
    August 11, 2010 - August 11, 2010 Failures in communication and information transfer across the surgical … July 6, 2012 An observational study of the frequency, severity, and etiology of failures … January 19, 2016 View More Related Resources Reducing failures … June 1, 2012 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

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40167/psn-pdf
    January 22, 2017 - Trainees' perceptions of patient safety practices: recounting failures of supervision. … Trainees' perceptions of patient safety practices: recounting failures of supervision. … https://psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision … https://psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision

  19. Techno Trip | PSNet

    psnet.ahrq.gov/web-mm/techno-trip
    May 01, 2005 - By preventing these sorts of failures, IT applications reduce the need for such workarounds. … Indeed, preventing such failures is one reason that IT is now being deployed. … failures are infrequent but potentially severe. … Although failures involving IT are often regarded as human (operator) error, these failures actually … March 11, 2011 The role of automation in complex system failures.

  20. Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA. | PSNet

    psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-medical-center
    March 16, 2022 - Electronic health record (EHR) implementation failures cause major disruptions to care delivery that … July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures
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