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Showing results for "failures".

  1. 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

  2. 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

  3. 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

  4. Active Error (or Active Failure) | PSNet

    psnet.ahrq.gov/taxonomy/term/3451
    Active failures are sometimes referred to as errors at the sharp end, figuratively referring to a scalpel … Latent errors (or latent conditions), in contrast, refer to less apparent failures of organization or

  5. Patients' experiences of dental diagnostic failures: a qualitative study using social media. | PSNet

    psnet.ahrq.gov/issue/patients-experiences-dental-diagnostic-failures-qualitative-study-using-social-media
    September 06, 2017 - Study Patients' experiences of dental diagnostic failures: a qualitative study using … Patients' experiences of dental diagnostic failures: a qualitative study using social media. … Patients' experiences of dental diagnostic failures: a qualitative study using social media.

  6. Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration. | PSNet

    psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment
    September 05, 2012 - Book/Report Work Design Drivers of Organizational Learning about Operational Failures … Citation Text: Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory … Citation Citation Text: Work Design Drivers of Organizational Learning about Operational Failures

  7. Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors. | PSNet

    psnet.ahrq.gov/issue/impact-interruptions-distractions-and-cognitive-load-procedure-failures-and-medication
    March 02, 2012 - Study Impact of interruptions, distractions, and cognitive load on procedure failures … Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration … Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration

  8. 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

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34784/psn-pdf
    June 24, 2015 - potential-improved-teamwork-reduce-medical-errors-emergency-department 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

  10. 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.

  11. 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 , … January 8, 2018 Inquiry into reporter's death finds multiple failures in care.

  12. Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids. | PSNet

    psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report
    January 22, 2014 - Study Identifying systems failures in the pathway to a catastrophic event: an analysis … Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident … Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident

  13. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. | PSNet

    psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient
    September 26, 2012 - Study Dropping the baton: a qualitative analysis of failures during the transition … 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

  14. 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

  15. 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

  16. 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.

  17. Murphy Diagram | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/murphy-diagram
    January 01, 2023 - Procedure execution Uses When analyzing failures retrospectively. … If the goal of the analysis is to predict potential failures, conduct a walkthrough of the events in … Offers useful application for tasks that involve teams, as it can portray teamwork and failures alongside

  18. Sensemakingnotes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
    August 08, 2012 - 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.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34735/psn-pdf
    June 16, 2014 - Organisation with a Memory set out to understand what was known about the scale and nature of serious failures … United Kingdom’s National Health Service (NHS) system, examine how the NHS might learn from those failures … , and recommend methods to minimize future failures.

  20. 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
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