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Showing results for "failures".

341. Sensemaking and Learn from Defects for Perinatal Safety (pdf 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.pdf
     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.

342. Sensemaking and Learn from Defects for Perinatal Safety (pdf 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.pdf
     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.

343. Sensemaking and Learn from Defects for Perinatal Safety (pdf 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.pdf
     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.

344. Sensemaking and Learn from Defects for Perinatal Safety (pdf 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.pdf
     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.

345. 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

346. 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

347. 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

348. 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

349. 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

350. 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

351. 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.

352. 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

353. 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

354. 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

355. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34775/psn-pdf
     February 07, 2019 - attendees, Berwick uses the story of the Mann Gulch Fire tragedy  to frame a series of reflections on the failures … He builds on the anecdotes by describing factors that contribute to an organization’s failures, once

356. 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

357. 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

358. 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

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47252/psn-pdf
     August 01, 2018 - https://psnet.ahrq.gov/issue/communication-errors-radiology-pitfalls-and-how-avoid-them Communication failures … communication-errors-radiology-pitfalls-and-how-avoid-them https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

360. 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