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Showing results for "failures".

201. 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

202. Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021. | PSNet
     psnet.ahrq.gov/issue/comprehensive-healthcare-inspection-summary-report-evaluation-care-coordination-veterans
     July 27, 2022 - Care coordination failures reduce the effectiveness of communication, information transfer, and patient … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … July 26, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

203. 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

204. 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

205. Contextual errors and failures in individualizing patient care: a multicenter study. | PSNet
     psnet.ahrq.gov/issue/contextual-errors-and-failures-individualizing-patient-care-multicenter-study
     October 29, 2012 - Study Classic Contextual errors and failures in individualizing … Contextual errors and failures in individualizing patient care: a multicenter study. … Contextual errors and failures in individualizing patient care: a multicenter study.

206. 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

207. 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

208. 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

209. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/notes.html
     December 01, 2012 - Examples of Defects or Failures That Affect Patient Safety Slide 9. … Active failures are also called human error. … 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.

210. 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

211. Losing Laura. | PSNet
     psnet.ahrq.gov/issue/losing-laura
     June 06, 2018 - Written by the patient's husband, the article outlines the failures that led to her death despite the … Factors discussed include overreliance on poorly functioning technology, communication failures , … June 26, 2019 Inquiry into reporter's death finds multiple failures in care.

212. 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

213. Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis. | PSNet
     psnet.ahrq.gov/issue/prevalence-causes-and-severity-medication-administration-errors-neonatal-intensive-care-unit
     January 17, 2024 - The review highlights both active failures (e.g., similar drug packaging or names) and latent failures … Improving Diagnostic Safety and Quality April 26, 2023 Latent and active failures

214. Operating room to intensive care unit handoffs and the risks of patient harm. | PSNet
     psnet.ahrq.gov/issue/operating-room-intensive-care-unit-handoffs-and-risks-patient-harm
     October 05, 2022 - The authors identified 81 process failures and outlined recommendations to mitigate many of these risks … October 2, 2013 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

215. Final Progress Report: A Pilot Study for Intrgrating Facility Information With Healthcare Information to Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/anumba-report_0.pdf
     January 01, 2024 - from those failures to their effects on the healthcare delivery system. … The FTAs link the listed failures through the possible and root causes. … The Failures class documents the failures that have been recorded. … e) The costs associated with facility failures can be considerable. … The cost impacts of facility failures on the healthcare delivery process; 4.

216. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845358/psn-pdf
     March 29, 2023 - research has documented implementation challenges and the potential for patient harm due to process failures … /psnet.ahrq.gov/issue/problem-medication-reconciliation https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors … https://psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events

217. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49581/psn-pdf
     March 21, 2009 - But a more robust analysis of a medication error allows reviewers to identify all the system failures … Latent Failures Latent failures are weaknesses in the structure of an organization and often include … Examples of such latent failures include the following: (i) lack of adequate drug information—no medication … Active Failures Active failures are errors committed by individuals, usually practitioners who are in … Active failures in this case included: (i) not viewing or checking the patient's complete medication

218. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33687/psn-pdf
     August 01, 2009 - More importantly, operational failures disrupt patient care, leading to uncompleted tasks and medical … Second, the lack of communication about failures keeps managers and relevant personnel unaware of the … Identification of systems failures in successful paediatric cardiac surgery. … The impact of operational failures on hospital nurses and their patients. … Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41:643-662.

219. The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures, and lessons learned, | PSNet
     psnet.ahrq.gov/issue/postpartum-hemorrhage-patient-safety-bundle-implementation-single-institution-successes
     February 01, 2023 - The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures … The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures … The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures

220. Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care. | PSNet
     psnet.ahrq.gov/issue/medication-reconciliation-failures-children-and-young-adults-chronic-disease-during-intensive
     June 22, 2022 - Study Medication reconciliation failures in children and young adults with chronic … Medication reconciliation failures in children and young adults with chronic disease during intensive … Medication reconciliation failures in children and young adults with chronic disease during intensive