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Showing results for "failures".

21. Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures. | PSNet
    psnet.ahrq.gov/issue/deficiencies-community-care-network-credentialing-process-former-va-surgeon-and-veterans
    November 29, 2023 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … network weakened by interorganizational communication gaps, data inconsistencies, and information failures … April 26, 2006 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … October 25, 2023 A System in Need of Repair: Addressing Organizational Failures of the

22. Operational failures in general practice: a consensus-building study on the priorities for improvement. | PSNet
    psnet.ahrq.gov/issue/operational-failures-general-practice-consensus-building-study-priorities-improvement
    February 07, 2024 - Study Operational failures in general practice: a consensus-building study on the … Operational failures in general practice: a consensus-building study on the priorities for improvement … Operational failures (e.g., distractions, situational constraints) can impact the delivery of safe, … Operational failures in general practice: a consensus-building study on the priorities for improvement … February 7, 2024 Impacts of operational failures on primary care physicians' work: a

23. Patient death tied to lack of proper escalation process for barcode scanning failures. | PSNet
    psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures
    November 01, 2023 - Article Patient death tied to lack of proper escalation process for barcode scanning failures … Citation Text: Patient death tied to lack of proper escalation process for barcode scanning failures … solution availability and staffing improvements are discussed to minimize opportunities for the systemic failures … Citation Citation Text: Patient death tied to lack of proper escalation process for barcode scanning failures … March 14, 2023 Latent and active failures perfectly align to allow a preventable adverse

24. Inquiry into reporter's death finds multiple failures in care. | PSNet
    psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care
    March 30, 2016 - Newspaper/Magazine Article Inquiry into reporter's death finds multiple failures … Citation Text: Inquiry into reporter's death finds multiple failures in care. Stout D. … The investigation uncovered a range of failures in emergency care and is described in a report available … Cite Citation Citation Text: Inquiry into reporter's death finds multiple failures

25. Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. | PSNet
    psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report
    July 18, 2018 - Book/Report Malpractice Risks in Communication Failures: 2015 Annual Benchmarking … Citation Text: Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … Communication failures are known to contribute to medical errors. … communication breakdowns led to patient harm, this report explores selected specialties where such failures … Cite Citation Citation Text: Malpractice Risks in Communication Failures

26. Preventing blood transfusion failures: FMEA, an effective assessment method. | PSNet
    psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method
    August 25, 2021 - Study Preventing blood transfusion failures: FMEA, an effective assessment method … Preventing blood transfusion failures: FMEA, an effective assessment method. … Preventing blood transfusion failures: FMEA, an effective assessment method.

27. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
    April 07, 2008 - Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures … Process failures were analyzed for likelihood, severity, and discoverability of occurrence using the … , such as poor logistics, equipment failures, and poor policies/procedures (Table 3). … Four of the failure modes were active failures. … However, despite this knowledge, many process flaws and team failures were identified.

28. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866080/psn-pdf
    June 05, 2024 - Giving up learning from failures? … Giving up learning from failures? … https://psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart … https://psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons … https://psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons

29. Weak oversight allows lab failures to put patients at risk. | PSNet
    psnet.ahrq.gov/issue/weak-oversight-allows-lab-failures-put-patients-risk
    June 12, 2019 - Newspaper/Magazine Article Weak oversight allows lab failures to put patients at … Citation Text: Weak oversight allows lab failures to put patients at risk. Gabler E. … methods, this news article discusses patients' experiences with testing errors to illustrate how such failures … Cite Citation Citation Text: Weak oversight allows lab failures

30. Communication failures contributing to patient injury in anaesthesia malpractice claims. | PSNet
    psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims
    August 04, 2021 - Study Communication failures contributing to patient injury in anaesthesia malpractice … Communication failures contributing to patient injury in anaesthesia malpractice claims. … malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures … Communication failures contributing to patient injury in anaesthesia malpractice claims.

31. Classification of failures in the perception of conversational agents (CAs) and their implications on patient safety. | PSNet
    psnet.ahrq.gov/issue/classification-failures-perception-conversational-agents-cas-and-their-implications-patient
    July 06, 2022 - Study Classification of failures in the perception of conversational agents (CAs) … Classification of failures in the perception of conversational agents (CAs) and their implications on … Investigators used these CAs to detect errors and failures in calculating correct insulin doses. … Potential failures must be considered before deployment of CAs in safety-critical environments. … Classification of failures in the perception of conversational agents (CAs) and their implications on

32. Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia. | PSNet
    psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical
    July 26, 2023 - Book/Report Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … Citation Text: Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer … Cancer test communication failures can contribute to physical, emotional, and financial patient harm. … Copy URL Cite Citation Citation Text: Multiple Failures … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

33. An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery. | PSNet
    psnet.ahrq.gov/issue/observational-study-frequency-severity-and-etiology-failures-postoperative-care-after-major
    August 11, 2010 - Study An observational study of the frequency, severity, and etiology of failures … An observational study of the frequency, severity, and etiology of failures in postoperative care after … This observational study at a large teaching hospital found that process failures in postoperative … An observational study of the frequency, severity, and etiology of failures in postoperative care after … August 11, 2010 Failures in communication and information transfer across the surgical

34. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/865930/psn-pdf
    May 22, 2024 - Operational failures in general practice: a consensus- building study on the priorities for improvement … Operational failures in general practice: a consensus-building study on the priorities for improvement … https://psnet.ahrq.gov/issue/operational-failures-general-practice-consensus-building-study-priorities … - improvement Operational failures (e.g., distractions, situational constraints) can impact the delivery … in the UK National Health Service (NHS), used a modified Delphi process to prioritize operational failures

35. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/843086/psn-pdf
    January 25, 2023 - Work environment and operational failures associated with nurse outcomes, patient safety, and patient … Work environment and operational failures associated with nurse outcomes, patient safety, and patient … Operational failures – breakdowns in care processes, such as distractions or situational constraints … using population-based survey data from 11,709 nurses examined the relationship between operational failures … Findings indicate that operational failures negatively impact patient satisfaction, quality and safety

36. 5 pandemic mistakes we keep repeating. We can learn from our failures. | PSNet
    psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures
    March 10, 2021 - We can learn from our failures. Citation Text: 5 pandemic mistakes we keep repeating. … We can learn from our failures. Zeynep Tufekci. The Atlantic. … February 26, 2021 Failures in communication have impacts on patients, teams, organizations and … We can learn from our failures. Zeynep Tufekci. The Atlantic.

37. Multiple latent failures align to allow a serious drug interaction to harm a patient. | PSNet
    psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient
    June 10, 2018 - Newspaper/Magazine Article Multiple latent failures align to allow a serious drug … Citation Text: Multiple latent failures align to allow a serious drug interaction to harm a patient … Detailing a case in which latent failures  led to patient harm, this article encourages health care … providers investigating adverse events to consider how both active and latent failures may line up … Copy URL Cite Citation Citation Text: Multiple latent failures

38. A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network. | PSNet
    psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-procurement-and
    August 10, 2022 - Congressional Testimony A System in Need of Repair: Addressing Organizational Failures … Citation Text: A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement … Blood-type mistakes , transport failures, and process challenges were amongst the problems discussed. … Citation Citation Text: A System in Need of Repair: Addressing Organizational Failures

39. Identifying the latent failures underpinning medication administration errors: an exploratory study. | PSNet
    psnet.ahrq.gov/issue/identifying-latent-failures-underpinning-medication-administration-errors-exploratory-study
    December 21, 2016 - Study Identifying the latent failures underpinning medication administration errors … Identifying the latent failures underpinning medication administration errors: an exploratory study. … This study identified 10 latent failures that contributed to medication administration errors based … Ward climate , the most prevalent theme, was noted to interact with other failures such as workload … Identifying the latent failures underpinning medication administration errors: an exploratory study.

40. Assessing system failures in operating rooms and intensive care units. | PSNet
    psnet.ahrq.gov/issue/assessing-system-failures-operating-rooms-and-intensive-care-units
    June 15, 2011 - Study Assessing system failures in operating rooms and intensive care units. … Assessing system failures in operating rooms and intensive care units. … The authors describe an instrument for identifying failures in the intensive care unit (ICU) and operating … room to help organizations gain insight into system failures in those high-risk environments. … Assessing system failures in operating rooms and intensive care units.