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Showing results for "failures".

  1. 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

  2. Spotlight Case September 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
    September 01, 2003 - Evidence for Communication Failures Poor communication between team members accounted for 37% of all … errors in a 4-month period of observation in critical units Communication failures contributed to 16% … Evidence for Communication Failures (cont.) … reviewed over the past 4 years (Weinger, et al., unpublished work), Taxonomy of Communication Failures … in a safe environment Videotapes analyzed later to identify performance failures and structure interventions

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37498/psn-pdf
    April 30, 2014 - preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures … a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures … and Structured communication tools are being used increasingly to prevent critical communication failures

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72536/psn-pdf
    December 02, 2020 - They include automation failures, the role of the obstetric anesthesiologist in maternal safety, and … https://psnet.ahrq.gov/issue/patient-safety-anesthetic-practice https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety

  5. Changing-System-Facilitator-Guide (doc file)

    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - These result in latent failures. … These result in active failures. … Slide 3 System Failures SAY: System failures are considered latent problems. … Slide 4 Active Failures SAY: Active failures occur because of human error. … Does the problem you are addressing involve latent failures, active failures, or both?

  6. Changing-System-Facilitator-Guide (doc file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
    June 01, 2021 - These result in latent failures. … These result in active failures. … Slide 3 System Failures SAY: System failures are considered latent problems. … Slide 4 Active Failures SAY: Active failures occur because of human error. … Does the problem you are addressing involve latent failures, active failures, or both?

  7. 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.

  8. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
    January 01, 2003 - Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities … 395 Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care … models provide contextual maps of the errors and behaviors that lead to medication delivery system failures … Risk modeling teams then identify the failures that link together, leading to the top-level event. … The models provide contextual maps of the errors and behaviors that lead to system failures so that

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

    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14295%20Shenep-draft-1.pdf
    June 01, 2005 - 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. The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. | PSNet

    psnet.ahrq.gov/issue/silent-treatment-why-safety-tools-and-checklists-arent-enough-save-lives
    April 03, 2009 - Silence Kills was a 2005 report that highlighted communication failures that contribute to patient … existing safety tools, such as checklists , are not in themselves solutions to these communication failures … June 10, 2018 Work Design Drivers of Organizational Learning about Operational Failures

  11. Patient reports of preventable problems and harms in primary health care. | PSNet

    psnet.ahrq.gov/issue/patient-reports-preventable-problems-and-harms-primary-health-care
    February 03, 2011 - breakdowns in the clinician–patient relationship as medical errors than adverse drug events or technical failures … January 18, 2013 Effect of reducing interns' weekly work hours on sleep and attentional failures … May 20, 2020 Failures in the respectful care of critically ill patients.

  12. An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer. | PSNet

    psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical
    June 12, 2013 - Organisation with a Memory set out to understand what was known about the scale and nature of serious failures … the United Kingdom’s National Health Service (NHS) system, examine how the NHS might learn from those failures … , and recommend methods to minimize future failures.

  13. 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/wysiwyg/research/findings/final-reports/anumba-report.pdf
    August 07, 2023 - 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.

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73454/psn-pdf
    June 30, 2021 - https://psnet.ahrq.gov/issue/poor-physician-patient-communication-and-medical-error Communication failures … issue/poor-physician-patient-communication-and-medical-error https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47477/psn-pdf
    November 14, 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, and

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867747/psn-pdf
    March 12, 2025 - issue/framework-analysis-communication-errors-health-care https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims … https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38712/psn-pdf
    June 17, 2009 - https://psnet.ahrq.gov/issue/silence-power-and-communication-operating-room Communication failures are … Interprofessional conflict can be a mediating factor in such failures, and this ethnographic study aimed … psnet.ahrq.gov/issue/silence-power-and-communication-operating-room https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40453/psn-pdf
    May 18, 2011 - This article discusses a patient who experienced delays in care due to a myriad of system failures in … The invited discussant explores the causes of these failures and discusses situational awareness, improved … The fact that JAMA chose a clinical scenario focusing on systems failures mirrors past efforts in the

  19. Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study. | PSNet

    psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits-middle-aged-and-older
    November 15, 2023 - Study Information management goals and process failures during home visits for middle-aged … Information management goals and process failures during home visits for middle-aged and older adults … Information management goals and process failures during home visits for middle-aged and older adults

  20. The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness. | PSNet

    psnet.ahrq.gov/issue/texas-health-presbyterian-hospital-ebola-crisis-perfect-storm-human-errors-system-failures
    February 23, 2018 - The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures … Text: The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures … Text: The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures
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