Results

Total Results: over 10,000 records

Showing results for "failures".

201. 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

202. 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.

203. 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

204. 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.

205. 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

206. 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

207. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/baker.html
     August 01, 2017 - Type of event seemed to affect what failures clinicians indicated should be disclosed, while type of … event had little effect on what failures patients and family members indicated should be disclosed. … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … We then examined the failures across events to create a common set of failures by the phases of the L … to the clinician rankings of the same failures.

208. 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

209. 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

210. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39082/psn-pdf
     January 04, 2010 - /communication-practices-4-harvard-surgical-services-surgical-safety- collaborative Communication failures … Further research is required to determine if these findings represent pure communication failures, challenges … -harvard-surgical-services-surgical-safety-collaborative https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps … https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

211. 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.

212. Application of root cause analysis on malpractice claim files related to diagnostic failures. | PSNet
     psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic-failures
     March 01, 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. … Application of root cause analysis on malpractice claim files related to diagnostic failures.

213. Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts. | PSNet
     psnet.ahrq.gov/issue/improving-patient-safety-governance-and-systems-through-learning-successes-and-failures
     May 08, 2017 - Improving patient safety governance and systems through learning from successes and failures … Improving patient safety governance and systems through learning from successes and failures: qualitative … Improving patient safety governance and systems through learning from successes and failures: qualitative … Perspectives on Safety Annual Perspective Impact of System Failures

214. Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia. | PSNet
     psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry
     September 28, 2017 - Study Patients' perspectives on quality and patient safety failures: lessons learned … Patients’ perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal … Patients’ perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal … September 28, 2017 Frequency and outcome of cervical cancer prevention failures in the

215. 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.

216. Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri. | PSNet
     psnet.ahrq.gov/issue/deficiencies-emergency-department-care-patient-who-died-suicide-john-cochran-division-va-st
     July 26, 2023 - This report shares recommendations to address leadership failures and other deficiencies including … July 5, 2023 Failures in Care Coordination and Reviewing a Patient's Death at the VA … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

217. Formative evaluation of the video reflexive ethnography method, as applied to the physician–nurse dyad. | PSNet
     psnet.ahrq.gov/issue/formative-evaluation-video-reflexive-ethnography-method-applied-physician-nurse-dyad
     December 02, 2020 - December 19, 2018 Using incident reports to assess communication failures and patient … October 13, 2018 Identification and characterization of failures in infectious agent … View More Related Resources Using incident reports to assess communication failures … November 14, 2012 Communication failures in the operating room: an observational classification

218. Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011. | PSNet
     psnet.ahrq.gov/issue/clinical-safety-englands-national-programme-it-retrospective-analysis-all-reported-safety
     December 31, 2014 - The researchers found that while most events were technical failures, incidents involving human errors … Technical failures affecting 10 or more patients accounted for nearly 25% of events and were more likely … May 10, 2013 Syndromic surveillance for health information system failures: a feasibility … November 2, 2010 A systematic review of failures in handoff communication during intrahospital

219. The perfect storm: exam of a medical error and factors contributing to its possible escalation. | PSNet
     psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation
     October 20, 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 … Investigations of all adverse events will help identify and correct system failures to improve patient

220. The potential for improved teamwork to reduce medical errors in the emergency department. | PSNet
     psnet.ahrq.gov/issue/potential-improved-teamwork-reduce-medical-errors-emergency-department
     July 07, 2021 - This article aims to introduce emergency department communities to teamwork systems, teamwork failures … that commonly occur, and the consequences of identified failures. … Discussion includes retrospective analysis of more than 50 incidents suggesting that nearly nine teamwork failures