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Showing results for "failures".

281. Maternity Pre-arrival Instructions by 999 Call Handlers. | PSNet
     psnet.ahrq.gov/issue/maternity-pre-arrival-instructions-999-call-handlers
     February 16, 2022 - Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise … November 4, 2020 Clinical Investigation Booking Systems Failures: Written Communications

282. How safety is compromised when hospital equipment is a poor fit for patients who are obese. | PSNet
     psnet.ahrq.gov/issue/how-safety-compromised-when-hospital-equipment-poor-fit-patients-who-are-obese
     October 07, 2020 - Download Citation Related Resources From the Same Author(s) Process failures … October 7, 2020 Patient harm resulting from medication reconciliation process failures … January 17, 2017 Preventing adverse events caused by emergency electrical power system failures

283. Factors contributing to preventing operating room "never events": a machine learning analysis. | PSNet
     psnet.ahrq.gov/issue/factors-contributing-preventing-operating-room-never-events-machine-learning-analysis
     July 26, 2023 - From the Same Author(s) Using failure mode and effect analysis to identify potential failures … November 30, 2016 Operational failures detected by frontline acute care nurses. … June 27, 2018 Participating in a multisite study exploring operational failures encountered

284. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46570/psn-pdf
     April 12, 2019 - electronic-health-records https://psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision … https://psnet.ahrq.gov/issue/trainees-perceptions-patient-safety-practices-recounting-failures-supervision

285. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/844546/psn-pdf
     February 15, 2023 - gender-biases-and-diagnostic-delay-inflammatory-bowel-disease-multicenter- observational-study Women often experience misdiagnosis and diagnostic delays due to process failures … psnet.ahrq.gov/issue/unwell-women-misdiagnosis-and-myth-man-made-world https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis

286. Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures. | PSNet
     psnet.ahrq.gov/issue/delayed-workup-rectal-bleeding-adult-primary-care-examining-process-care-failures
     April 24, 2018 - Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures … Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures. … Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures.

287. USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ppe-covid19-audit-tracking-tool-userguide.pdf
     April 01, 2021 - The tracking tool only extracts the failures in each category, so you are only required to select "NO … The tab will then automatically calculate how many “Not Met” observations or failures, were recorded … provides a high-level summary of the audit data for your facility, including and the average number of failures … (NO/Not Met) per audit, and a breakdown of where the failures are occurring by both line item and category … The Summary Rates tab provides graphs outlining the average number of failures per audit and the PPE

288. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
     April 01, 2021 - The tracking tool only extracts the failures in each category, so you are only required to select "NO … The tab will then automatically calculate how many “Not Met” observations or failures, were recorded … provides a high-level summary of the audit data for your facility, including and the average number of failures … (NO/Not Met) per audit, and a breakdown of where the failures are occurring by both line item (#1 - … The Summary Rates tab provides graphs outlining the average number of failures per audit and the hand

289. Frequency and outcome of cervical cancer prevention failures in the United States. | PSNet
     psnet.ahrq.gov/issue/frequency-and-outcome-cervical-cancer-prevention-failures-united-states
     April 09, 2013 - Study Frequency and outcome of cervical cancer prevention failures in the United … Frequency and outcome of cervical cancer prevention failures in the United States. … Frequency and outcome of cervical cancer prevention failures in the United States.

290. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60277/psn-pdf
     January 01, 2021 - included inadequate communication among providers (55%), failure to respond (41%), and documentation failures … Both diagnosis-related and physiologic monitoring cases listing communication failures among providers

291. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841478/psn-pdf
     December 14, 2022 - The review highlights both active failures (e.g., similar drug packaging or names) and latent failures

292. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38881/psn-pdf
     November 08, 2012 - This column recounts a case of delayed diagnosis and examines how communication and process of care failures … issue/are-patients-part-blame-when-doctors-miss-diagnosis https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis

293. Machine learning is booming in medicine. It’s also facing a credibility crisis. | PSNet
     psnet.ahrq.gov/issue/machine-learning-booming-medicine-its-also-facing-credibility-crisis
     May 22, 2019 - This news story highlights how underlying problems and testing failures limit the trustworthiness … December 1, 2021 Pathology Oversight Failures at the Veterans Health Care System of the

294. Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. | PSNet
     psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs
     October 07, 2020 - This report summarizes an investigation of 25 imaging failures in the British National Health Service … October 5, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

295. Final Progress Report: Improving ED Quality and Safety by Enhancing Operations and Quality Management (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/khare-report.pdf
     January 01, 2024 - Of the 12 high-risk failures, 58% occurred between ECG and catheterization laboratory activation. … An FMECA elicits information about any failures for each step in a process including the underlying … An FMECA also permitted ranking of failures from high to low risk. … The failures were then “binned” into high-, medium-, and low-risk bins. … To the degree possible, both hospitals tried to work on similar failures.

296. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866111/psn-pdf
     June 12, 2024 - 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

297. Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus. | PSNet
     psnet.ahrq.gov/issue/electronic-health-record-modernization-caused-pharmacy-related-patient-safety-issues
     January 31, 2024 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … January 24, 2024 Multiple Failures in Test Results Follow-up for a Patient Diagnosed … October 25, 2023 Failures in Care Coordination and Reviewing a Patient's Death at the

298. Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives. | PSNet
     psnet.ahrq.gov/issue/routine-failures-process-blood-testing-and-communication-results-patients-primary-care-uk
     November 20, 2015 - Study Routine failures in the process for blood testing and the communication of … Routine failures in the process for blood testing and the communication of results to patients in primary … Routine failures in the process for blood testing and the communication of results to patients in primary

299. Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. | PSNet
     psnet.ahrq.gov/issue/deficiencies-emergent-and-outpatient-care-patient-alcohol-use-disorder-richard-l-roudebush-va
     July 13, 2022 - Copy Citation Related Resources From the Same Author(s) Multiple Failures … July 26, 2023 Failures in Care Coordination and Reviewing a Patient's Death at the VA … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

300. Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery. | PSNet
     psnet.ahrq.gov/issue/computer-assisted-process-modeling-enhance-intraoperative-safety-cardiac-surgery
     July 19, 2023 - 12, 2009 View More Related Resources Giving up learning from failures … An examination of learning from one's own failures in the context of heart surgeons. … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures