Results

Total Results: over 10,000 records

Showing results for "failures".

261. 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

262. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
     April 07, 2008 - Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures … Process failures were analyzed for likelihood, severity, and discoverability of occurrence using the … , such as poor logistics, equipment failures, and poor policies/procedures (Table 3). … Four of the failure modes were active failures. … However, despite this knowledge, many process flaws and team failures were identified.

263. 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

264. 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

265. 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

266. Does nurse use of a standardized flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures? A retrospective study of electronic health record data. | PSNet
     psnet.ahrq.gov/issue/does-nurse-use-standardized-flowsheet-document-communication-advanced-providers-provide
     June 22, 2022 - flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures … flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures … flowsheet to document communication with advanced providers provide a mechanism to detect pulse oximetry failures

267. 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

268. 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

269. 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.

270. 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

271. 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

272. The practice of respect in the ICU. | PSNet
     psnet.ahrq.gov/issue/practice-respect-icu
     August 09, 2018 - the need to expand the research on respect in the intensive care unit and the value of responding to failures … October 19, 2022 Failures in the respectful care of critically ill patients. … April 13, 2022 Failures in the respectful care of critically ill patients.

273. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/861292/psn-pdf
     January 24, 2024 - Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … network weakened by interorganizational communication gaps, data inconsistencies, and information failures

274. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60648/psn-pdf
     July 01, 2020 - //psnet.ahrq.gov/issue/chronicle-pandemic-foretold-learning-covid-19-failure-next-outbreak-arrives Failures … failure-next-outbreak-arrives https://psnet.ahrq.gov/issue/dennis-quaids-quest https://psnet.ahrq.gov/issue/identifying-systems-failures-pathway-catastrophic-event-analysis-national-incident-report

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74005/psn-pdf
     October 27, 2021 - 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

276. 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

277. Swiss Cheese Model | PSNet
     psnet.ahrq.gov/glossary/swiss-cheese-model
     September 13, 2021 - developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures … tend to reveal multiple, smaller failures leading up to the actual hazard.

278. 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

279. 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

280. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47596/psn-pdf
     March 27, 2019 - Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures