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Showing results for "failures".

  1. Swiss Cheese Model | PSNet

    psnet.ahrq.gov/taxonomy/term/3460
    August 11, 2025 - 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.

  2. 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

  3. 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

  4. 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

  5. What do patients and relatives know about problems and failures in care? | PSNet

    psnet.ahrq.gov/issue/what-do-patients-and-relatives-know-about-problems-and-failures-care
    November 28, 2016 - Study What do patients and relatives know about problems and failures in care? … What do patients and relatives know about problems and failures in care? … What do patients and relatives know about problems and failures in care?

  6. Communication failures in the operating room: an observational classification of recurrent types and effects. | PSNet

    psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and
    April 06, 2011 - Study Classic Communication failures in the operating room … Communication failures in the operating room: an observational classification of recurrent types and … Communication failures in the operating room: an observational classification of recurrent types and

  7. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
    July 01, 2023 - Failure Mode and Effects Analysis Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects … Slide 7: Examples of Defects or Failures That Affect Patient Safety Defect Intervention … Defects or failures are clinical or operational events that you do not want to happen again.

  8. Temporarily holding medication orders safely in order to prevent patient harm. | PSNet

    psnet.ahrq.gov/issue/temporarily-holding-medication-orders-safely-order-prevent-patient-harm
    March 14, 2023 - , 2023 Patient death tied to lack of proper escalation process for barcode scanning failures … October 4, 2023 Latent and active failures perfectly align to allow a preventable adverse … April 5, 2023 Latent and active failures perfectly align to allow a preventable adverse

  9. 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

  10. Latent Error (or Latent Condition) | PSNet

    psnet.ahrq.gov/glossary/latent-error-or-latent-condition
    September 13, 2021 - Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed … Active failures, in contrast, are sometimes referred to as errors at the sharp end, or the personnel

  11. Staff Safety Assessment

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
    January 01, 2006 - and Effects Analysis -Probabilistic Risk Assessment Tools to examine defects or failures … Learn from Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … information by residents during rounds Electronic progress note developed Examples of Defects or Failures … Sensemaking and Identifying Defects Identify defects and Sensemaking share several common themes Defects or failures

  12. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - Failure Mode and Effects Analysis - Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … 6 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Examples of Defects or Failures … Sensemaking and Learn From Defects Sensemaking and Learn From Defects share several common themes Defects or failures

  13. 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

  14. Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions. | PSNet

    psnet.ahrq.gov/issue/delayed-recognition-deterioration-patients-general-wards-mostly-caused-human-related
    December 21, 2017 - recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures … Recognition of Deterioration of Patients in General Wards Is Mostly Caused by Human Related Monitoring Failures … Recognition of Deterioration of Patients in General Wards Is Mostly Caused by Human Related Monitoring Failures

  15. 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

  16. Lafleur, Joanne | Agency for Healthcare Research and Quality

    www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumlafl.html
    October 01, 2014 - The grantee is interested in identifying and preventing drug-therapy failures in chronic disease populations … She is focusing on the clinical area of osteoporosis for systems interventions to prevent such failures

  17. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
    July 01, 2007 - have negative effects on survival from cardiac arrest List the most common causes of defibrillator failures … Defibrillator failures: causes of problems and recommendations for improvement. … failures due to device-related issues Failure to properly maintain and check devices Batteries not … Defibrillator failures: causes of problems and recommendations for improvement. … Defibrillator failures: causes of problems and recommendations for improvement.

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867337/psn-pdf
    December 11, 2024 - perspectives-anesthesia-and-perioperative-patient-safety-past-present-and- future Achieving sustained improvements in patient safety requires learning from both safety failures … The Safety I framework includes using individual and system failures, analytics, culture, and technology

  19. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
    September 01, 2020 - identity. 2 These checklists are meant to prevent errors of execution, so-called “slips” (attention failures … ) or “lapses” (memory failures). 20 Typical for these errors is that the clinician had the right plan

  20. Module 3: Systems Change: Understanding Your Workflow Processes To Prepare for System Change | Agency for Healthcare Research and Quality

    www.ahrq.gov/takeheart/training/module-3/index.html
    December 01, 2022 - attendees should be able to: Understand the importance of mapping key processes and identifying process failures … Identify implementation gaps and process failures that must be addressed to support automatic referral
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