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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42875/psn-pdf
    January 22, 2014 - operating room identified six key concepts: indicators of effective communication, signs of communication failures … https://psnet.ahrq.gov/issue/communication-operating-theatre https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

  2. Identifying failure modes in telemedicine: an instructional needs assessment. | PSNet

    psnet.ahrq.gov/issue/identifying-failure-modes-telemedicine-instructional-needs-assessment
    August 23, 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

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845277/psn-pdf
    March 01, 2023 - effects, and criticality analysis (FMECA) to create an acute stroke diagnostic process map, identify failures … The FMECA process identified several steps in the diagnostic process as the most critical failures to

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41416/psn-pdf
    May 23, 2012 - emphasizes the importance of anesthesiologists performing pre-surgery safety checks to prevent equipment failures … association-anaesthetists-great-britain-and-ireland https://psnet.ahrq.gov/issue/analysis-major-errors-and-equipment-failures-anesthesia-management-considerations-prevention

  5. Patient Safety: A Case-based Innovative Playbook for Safer Care. Second Edition. | PSNet

    psnet.ahrq.gov/issue/patient-safety-case-based-innovative-playbook-safer-care-second-edition
    September 11, 2019 - emerged in prominence due to the COVID-19 pandemic (health disparities, inequities and nursing home care failures … August 28, 2019 Mistakes, Errors and Failures across Cultures.

  6. Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. | PSNet

    psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals
    June 16, 2019 - (experts from the Institute for Safe Medication Practices) discovered more than 50 latent system failures … The authors discuss the need to look beyond individuals and focus on the multiple system failures that

  7. A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays. | PSNet

    psnet.ahrq.gov/issue/25-year-old-teacher-died-after-waiting-hours-er-shes-not-only-one-who-saw-delays
    September 09, 2020 - Delays in emergency room (ER) triage and assessment contribute to wide range of failures that degrade … September 9, 2020 Weak oversight allows lab failures to put patients at risk.

  8. Module-3-Slides (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-slides.pdf
    February 09, 2022 - Learning Goals 6 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 … Insights From Workflow Process Maps 22 PARTICIPANTS Use process maps to identify process gaps and failures … Use Fishbone diagrams to group failures into categories that your redesigned processes will need … Failure to refer all patients eligible for CR Patient objection to referral Referral process failures

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47477/psn-pdf
    November 14, 2018 - Written by the patient's husband, the article outlines the failures that led to her death despite the … Factors discussed include overreliance on poorly functioning technology, communication failures, and

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43603/psn-pdf
    October 15, 2014 - psnet.ahrq.gov/issue/coaching-improve-quality-communication-during-briefings-and-debriefings Communication failures … coaching-improve-quality-communication-during-briefings-and-debriefings https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

  11. Final Progress Report: Older adult safety while receiving home health services after hospital discharge (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/arbaje-report.pdf
    January 01, 2024 - Examples of the most frequent risk factors contributing to IM- related process failures were as follows … We identified numerous consequences resulting from IM-related process failures (e.g., delays in care … IM-related process failures are associated with wide- ranging consequences that can affect older adults … We identified IM-related process failures, risk factors, and outcomes that can serve as measures health … Information management goals and process failures during home visits for middle-aged and older adults

  12. Intubation Mishap | PSNet

    psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - Coordination is dependent on effective communication.( 4 ) The Evidence for Communication Failures … At Dartmouth-Hitchcock Medical Center, failures of team communication were identified in 61% of the 42 … Taxonomy of Communication Failures . … —There are many types of communication failures and many ways to classify them. … Fundamentally, they can be broken down into failures of message transmission and reception.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836812/psn-pdf
    March 30, 2022 - analysis (FMEA) is a structured adverse event analysis tool that aims to prospectively identify potential failures … The goal of FMEA is to prioritize failures based on their potential seriousness and to design and implement … actions to mitigate or prevent failures in order of priority. … The term “effects analysis” refers to analyzing the consequences of such failures by prioritizing their … improving-process-while-changing-practice-fmea-and-medication-administration https://psnet.ahrq.gov/issue/preventing-blood-transfusion-failures-fmea-effective-assessment-method

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45160/psn-pdf
    May 18, 2016 - primary-care-closed-claims-experience-massachusetts-malpractice-insurers https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures … -2015-annual-benchmarking-report https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44889/psn-pdf
    April 13, 2017 - /organizational-learning-framework-patient-safety Organizations are encouraged to learn from their failures … This commentary presents a model to help organizations learn from system failures through focusing on

  16. The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. | PSNet

    psnet.ahrq.gov/issue/differences-between-human-error-risk-behavior-and-reckless-behavior-are-key-just-culture
    September 23, 2020 - different types of flawed human behavior and designing effective organizational responses to these failures … March 27, 2024 Latent and active failures perfectly align to allow a preventable adverse

  17. Allowing failure for educational purposes in postgraduate clinical training: a narrative review. | PSNet

    psnet.ahrq.gov/issue/allowing-failure-educational-purposes-postgraduate-clinical-training-narrative-review
    February 08, 2023 - This review examined the use of learning from failures in postgraduate medicine and found further research … Download Citation Related Resources From the Same Author(s) Using trainee failures

  18. Critical Deficiencies at the Washington DC VA Medical Center. | PSNet

    psnet.ahrq.gov/issue/critical-deficiencies-washington-dc-va-medical-center
    December 16, 2020 - Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures . … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures

  19. The rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient safety. | PSNet

    psnet.ahrq.gov/issue/rising-frequency-it-blackouts-indicates-increasing-relevance-it-emergency-concepts-ensure
    October 12, 2022 - This review discusses ways to protect against large-scale failures of health IT systems and categorizes … the types of failures that can occur.

  20. Unstoppable: this doctor has been investigated at every level of government. How is he still practicing? | PSNet

    psnet.ahrq.gov/issue/unstoppable-doctor-has-been-investigated-every-level-government-how-he-still-practicing
    September 16, 2020 - Systemic failures can enable poor practice to perpetuate without regard to safety. … More Related Resources Patients' perspectives on quality and patient safety failures
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