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Total Results: over 10,000 records

Showing results for "failures".

321. A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis. | PSNet
     psnet.ahrq.gov/issue/perfect-storm-averted-flawed-systems-dropped-ball-and-cognitive-biases-delay-critical
     November 30, 2022 - disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures … September 8, 2021 Preventing and mitigating radiology system failures: a guide to disaster

322. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. | PSNet
     psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
     April 27, 2019 - A prospective failure mode and effect analysis identified 57 potential failures that each could lead … Most of these potential failures require technological rather than educational or policy-based solutions

323. A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds. | PSNet
     psnet.ahrq.gov/issue/pilot-study-examining-undesirable-events-among-emergency-department-boarded-patients-awaiting
     August 04, 2021 - A prior study found that communication failures were a contributing factor to errors in this situation … October 15, 2014 Inquiry into reporter's death finds multiple failures in care.

324. Semantically ambiguous language in the teaching operating room. | PSNet
     psnet.ahrq.gov/issue/semantically-ambiguous-language-teaching-operating-room
     November 11, 2020 - Communication failures are a common cause of patient harm. … November 17, 2021 Communication failures contributing to patient injury in anaesthesia

325. Effects of interdisciplinary collaboration in hospitals on medication errors: an integrative review. | PSNet
     psnet.ahrq.gov/issue/effects-interdisciplinary-collaboration-hospitals-medication-errors-integrative-review
     June 16, 2021 - Communication failures hinder safety of health care delivery and are particularly prevalent in medication … September 6, 2017 Failures in communication through documents and documentation across

326. Scandal as a sentinel event—recognizing hidden cost–quality trade-offs. | PSNet
     psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs
     November 04, 2020 - Latent factors are known to contribute to system-level failures. … meet performance targets and insufficient safety culture led to unintended consequences and system failures

327. 2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database. | PSNet
     psnet.ahrq.gov/issue/2020-pennsylvania-patient-safety-reporting-analysis-serious-events-and-incidents-nations
     July 06, 2022 - July 13, 2022 Patient harm resulting from medication reconciliation process failures: … June 29, 2022 Process failures that increase the risk of infection through respiratory … January 19, 2022 Communication failures contributing to patient injury in anaesthesia

328. Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020. | PSNet
     psnet.ahrq.gov/issue/comprehensive-healthcare-inspection-summary-report-evaluation-mental-health-veterans-health
     July 13, 2022 - Copy Citation Related Resources From the Same Author(s) Multiple Failures … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … April 19, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

329. Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals. | PSNet
     psnet.ahrq.gov/issue/safety-events-impacting-hospitalized-patients-following-motor-vehicle-crashes-qualitative
     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 … 2020 Health literacy-related safety events: a qualitative study of health literacy failures

330. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40690/psn-pdf
     August 17, 2011 - designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure- mode-and-effect A prospective failure mode and effect analysis identified 57 potential failures … Most of these potential failures require technological rather than educational or policy-based solutions

331. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34721/psn-pdf
     November 19, 2015 - The most common types of preventable events are technical errors, errors in diagnosis, failures of prevention … Diagnostic mishaps and late surgical failures had the highest rates of preventability.

332. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45188/psn-pdf
     June 01, 2016 - This newsletter article discusses how workarounds serve as indicators of system failures and present … reporting-and-second-order-problem-solving-can-turn-short-term-fixes-long-term-remedies https://psnet.ahrq.gov/issue/work-design-drivers-organizational-learning-about-operational-failures-laboratory-experiment

333. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38544/psn-pdf
     September 02, 2009 - A prior study found that communication failures were a contributing factor to errors in this situation … pilot-study-examining-undesirable-events-among-emergency-department-boarded-patients-awaiting https://psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient

334. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - Unlike active failures, which are difficult to predict, latent conditions can be identified and remedied … The learning lab also identified 10 precarious events (active failures) that were the result of JACHO … Errors in health care, like human failures in any other sphere, are not just isolated causes; they are … Advances in Patient Safety: Vol. 2 430 Active failures Operative/postop complications/infections … This will result in reducing the latent conditions and active failures that lead to error.

335. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - Background: Reviews of recent research-related fatalities have demonstrated that clinical research system failures … : Collecting research unit-specific information on potential safety concerns could identify system failures … Typically the same system failures that might have resulted in an injury also are present in a near … However, these latent failures serve as “holes” in the usual safety mechanisms. … Other novel methods to identify and mange potential system failures in clinical research need to be

336. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47064/psn-pdf
     August 22, 2018 - psnet.ahrq.gov/issue/lax-oversight-leaves-surgery-center-regulators-and-patients-dark High-profile failures … Enhanced transparency regarding those failures can enable informed patient decision-making when choosing

337. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33589/psn-pdf
     September 15, 2024 - operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures … complexity of operations and the risk of significant and even potentially catastrophic consequences when failures … thinking: preoccupation with failure; reluctance to simplify explanations for operations, successes, and failures … resilience is rooted in the fundamental understanding of the frequently unpredictable nature of system failures

338. Building patient safety skills: common pitfalls when conducting a root cause analysis. | PSNet
     psnet.ahrq.gov/issue/building-patient-safety-skills-common-pitfalls-when-conducting-root-cause-analysis
     May 07, 2018 - This piece highlights common failures in root cause analysis  (RCA) and explains how each undermines … June 27, 2018 Multiple latent failures align to allow a serious drug interaction to harm

339. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45815/psn-pdf
     January 25, 2017 - Improvement efforts have focused on care transitions, which are known to be vulnerable to communication failures … psnet.ahrq.gov/primer/handoffs-and-signouts https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-failures-childrens-hospitals

340. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39064/psn-pdf
     October 28, 2009 - Use of failure mode and effects analysis for proactive identification of communication and handoff failures … Use of failure mode and effects analysis for proactive identification of communication and handoff failures