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Showing results for "failures".

  1. 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.

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865594/psn-pdf
    January 01, 2025 - understanding-informal-aspects-medication-processes-maintain-patient-safety- hospitals Medication errors are often the result of both individual failures … psnet.ahrq.gov/primer/medication-administration-errors https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers

  3. Double Dosing, by the Rules | PSNet

    psnet.ahrq.gov/web-mm/double-dosing-rules
    February 03, 2010 - But a more robust analysis of a medication error allows reviewers to identify all the system failures … developing system strategies to reduce or eliminate medication errors.( 2 ) Both latent and active failures … Latent Failures Latent failures are weaknesses in the structure of an organization and often include … Active Failures Active failures are errors committed by individuals, usually practitioners who are … Active failures in this case included: (i) not viewing or checking the patient's complete medication

  4. 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.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42900/psn-pdf
    September 19, 2016 - The case reviews revealed communication failures, such as lack of discussion about suicide risks or … sentinel-event-alert https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps … https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps https://psnet.ahrq.gov

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38076/psn-pdf
    February 15, 2011 - consequences-inadequate-sign-out-patient-care With reductions in resident work hours, a greater number of communication failures … The authors also reported that failures to provide an accurate overall picture of the patient led to … common-program-requirements-learning-and-working-environment-duty-hours https://psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident

  7. Overreaction. | PSNet

    psnet.ahrq.gov/issue/overreaction
    November 15, 2023 - August 28, 2019 Operational failures detected by frontline acute care nurses. … Hemolysis Holdup May 1, 2017 Weak oversight allows lab failures … October 8, 2013 Inquiry into reporter's death finds multiple failures in care.

  8. Chapter 2. What is Care Coordination? | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/care/coordination/atlas/chapter2.html
    June 01, 2014 - Perspectives on Care Coordination Successes and failures in care coordination will be perceived (and … and sites are met over time. 4 Patients, their families, and other informal caregivers experience failures … Patients perceive failures in terms of unreasonable levels of effort required on the part of themselves … They also perceive failures in terms of unreasonable levels of effort required on their part in order … Successes and failures in care coordination will be perceived (and may be measured) in different ways

  9. Postoperative handover: problems, pitfalls, and prevention of error. | PSNet

    psnet.ahrq.gov/issue/postoperative-handover-problems-pitfalls-and-prevention-error
    September 26, 2012 - RIS Download Citation Related Resources From the Same Author(s) Failures … July 6, 2012 An observational study of the frequency, severity, and etiology of failures … February 23, 2011 Surgical technology and operating-room safety failures: a systematic … October 27, 2022 An observational study of postoperative handoff standardization failures

  10. Implement strategies to prevent persistent medication errors and hazards: 2024. | PSNet

    psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024
    April 17, 2024 - Systemic failures can perpetuate unsafe care if a lack of prioritization distracts from efforts to … April 5, 2023 Latent and active failures perfectly align to allow a preventable adverse

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73639/psn-pdf
    August 25, 2021 -   https://psnet.ahrq.gov/issue/safety-maternity-services-england High-profile failures motivate … This report builds on maternity care failures in National Health Service trusts to recommend needed

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852278/psn-pdf
    August 09, 2023 - study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures … Four categories of failures were identified: technical issues, patient safety, communication, and social

  13. Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios. | PSNet

    psnet.ahrq.gov/issue/inattentional-blindness-and-failures-rescue-deteriorating-patient-critical-care-emergency-and
    October 12, 2016 - Study Inattentional blindness and failures to rescue the deteriorating patient in … Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency … Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency

  14. Pump up the volume: how to prioritize events and analyze error data. | PSNet

    psnet.ahrq.gov/issue/pump-volume-how-prioritize-events-and-analyze-error-data
    March 14, 2023 - March 3, 2021 Latent and active failures perfectly align to allow a preventable adverse … , 2023 Patient death tied to lack of proper escalation process for barcode scanning failures … February 8, 2023 Latent and active failures perfectly align to allow a preventable adverse

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74212/psn-pdf
    January 01, 2022 - Using failure mode and effects analysis (FMEA), researchers identified potential failures related to … Common failures included incorrect patient information, non-standardized chemotherapy protocols, and

  16. Information transfer and communication in surgery: a systematic review. | PSNet

    psnet.ahrq.gov/issue/information-transfer-and-communication-surgery-systematic-review
    September 26, 2012 - This systematic review of 38 published studies identified communication failures in all phases of surgical … RIS Download Citation Related Resources From the Same Author(s) Failures … February 9, 2011 An observational study of the frequency, severity, and etiology of failures

  17. Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique. | PSNet

    psnet.ahrq.gov/issue/teaching-nursing-students-ethical-and-legal-consequences-medical-errors-insights-radonda
    July 05, 2017 - students reported greater understanding of error reporting, the role of state boards of nursing, system failures … Download Citation Related Resources From the Same Author(s) Operational failures … April 17, 2024 Systemic failures in health care oversight.

  18. Executive Summary | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
    June 01, 2023 - explores: How patient-reported experiences can augment other methods of identifying diagnostic failures … Feedback from patient experiences can be useful for addressing diagnostic failures in two distinct ways

  19. Silence, power and communication in the operating room. | PSNet

    psnet.ahrq.gov/issue/silence-power-and-communication-operating-room
    June 08, 2011 - Communication failures are a known problem in operating rooms, with past studies examining the role … Interprofessional conflict can be a mediating factor in such failures, and this ethnographic study … August 10, 2011 Communication failures in the operating room: an observational classification

  20. Technology, Education and Safety. | PSNet

    psnet.ahrq.gov/issue/technology-education-and-safety
    December 15, 2021 - They include automation failures , the role of the obstetric anesthesiologist in maternal safety , … March 27, 2024 Automation failures and patient safety.
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