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Showing results for "failures".

  1. 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

  2. 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.

  3. Taxonomic Guidance for Remedial Actions (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
    December 23, 2004 - Technical problems (machine failures) 2. Organizational problems 3. … Human performance failures 4. … Of the organizational failures, those easiest to fix (training, and then protocols) come first. … This taxonomy addresses failures in health care settings. … refer to failures in the performance of fine motor skills, and tripping refers to failures in whole

  4. Swiss Cheese Model | PSNet

    psnet.ahrq.gov/taxonomy/term/3460
    January 20, 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.

  5. 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

  6. 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

  7. Learn-From-Defects-Facilitator-Guide (doc file)

    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

  8. Learn-From-Defects-Facilitator-Guide (doc file)

    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

  9. Learn-From-Defects-Facilitator-Guide (doc file)

    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

  10. Learn-From-Defects-Facilitator-Guide (doc file)

    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

  11. Learn-From-Defects-Facilitator-Guide (doc file)

    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

  12. Learn-From-Defects-Facilitator-Guide (doc file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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.

  18. 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

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

    www.ahrq.gov/patient-safety/reports/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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