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Showing results for "failures".

  1. Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes. | PSNet

    psnet.ahrq.gov/issue/improving-medication-administration-safety-using-naive-observation-assess-practice-and-guide
    October 06, 2016 - April 24, 2018 Operational failures detected by frontline acute care nurses. … One Bronchoscopy, Two Errors January 1, 2019 Inattentional blindness and failures … recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures

  2. A multicenter collaborative approach to reducing pediatric codes outside the ICU. | PSNet

    psnet.ahrq.gov/issue/multicenter-collaborative-approach-reducing-pediatric-codes-outside-icu
    August 13, 2014 - Related Resources From the Same Author(s) Decreasing handoff-related care failures … July 19, 2023 Operational failures detected by frontline acute care nurses. … Improving Diagnostic Safety and Quality April 26, 2023 Using trainee failures

  3. Systems approaches to surgical quality and safety: from concept to measurement. | PSNet

    psnet.ahrq.gov/issue/systems-approaches-surgical-quality-and-safety-concept-measurement
    January 19, 2016 - October 20, 2014 Surgical technology and operating-room safety failures: a systematic … March 3, 2011 An observational study of the frequency, severity, and etiology of failures … August 15, 2013 Surgical technology and operating-room safety failures: a systematic

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46024/psn-pdf
    June 15, 2017 - issue/introductions-during-time-outs-do-surgical-team-members-know-one-anothers- names Communication failures … introductions-during-time-outs-do-surgical-team-members-know-one-anothers-names https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44577/psn-pdf
    October 21, 2015 - improving-patient-safety-clinical-oncology-applying-lessons-normal-accident- theory The Normal Accident Theory suggests that failures … are inevitable in complex environments, but proactive analysis of potential failures within systems

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45493/psn-pdf
    December 07, 2016 - This review discusses ways to protect against large-scale failures of health IT systems and categorizes … the types of failures that can occur.

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43040/psn-pdf
    March 05, 2014 - derived from James Reason’s model of organizational accidents, which differentiates active from latent failures … psnet.ahrq.gov/issue/managing-risks-organizational-accidents https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

  8. Analyzing and discussing human factors affecting surgical patient safety using innovative technology: creating a safer operating culture. | PSNet

    psnet.ahrq.gov/issue/analyzing-and-discussing-human-factors-affecting-surgical-patient-safety-using-innovative
    August 25, 2021 - These events primarily involved communication failures, poor teamwork, and situational awareness failures

  9. Where are my instruments? Hazards in delivery of surgical instruments. | PSNet

    psnet.ahrq.gov/issue/where-are-my-instruments-hazards-delivery-surgical-instruments
    September 25, 2008 - March 29, 2023 Reducing failures in daily medical practice: healthcare failure mode … June 1, 2012 Assessing system failures in operating rooms and intensive care units. … Use of failure mode and effects analysis for proactive identification of communication and handoff failures

  10. Confidential clinician-reported surveillance of adverse events among medical inpatients. | PSNet

    psnet.ahrq.gov/issue/confidential-clinician-reported-surveillance-adverse-events-among-medical-inpatients
    June 29, 2011 - January 6, 2017 Process of care failures in breast cancer diagnosis. … Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures … August 3, 2022 Using incident reports to assess communication failures and patient outcomes

  11. SynergyHealth - St. Joseph's Hospital: Designing a safe hospital (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/2006Reiling_052411comp.pdf
    January 01, 2005 - Source: To Err is Human, Institute of Medicine Active Failures An error that occurs at the level … service – Minimize Handoffs – Minimize Patient Movement Design Recommendations, con’t • Active Failures … question the need for tests, treatments or meds •7% refused a test, tx or med Reduce Active Failures … Designing a safe hospital Managing the risks of organizational accidents Latent Conditions �Active Failures

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37378/psn-pdf
    February 24, 2011 - medication-discrepancies-resident-sign-outs-and-their-potential-harm Efforts to standardize hand-offs remain a critical part of preventing communication failures … psnet.ahrq.gov/issue/model-building-standardized-hand-protocol https://psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40355/psn-pdf
    July 09, 2012 - silent-treatment-why-safety-tools-and-checklists-arent-enough-save-lives Silence Kills was a 2005 report that highlighted communication failures … existing safety tools, such as checklists, are not in themselves solutions to these communication failures

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49415/psn-pdf
    September 01, 2003 - 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 … 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.

  15. The Safety of Maternity Services in England. | PSNet

    psnet.ahrq.gov/issue/safety-maternity-services-england
    February 04, 2015 - High-profile failures motivate examination and change of existing services. … This report builds on maternity care failures in National Health Service trusts to recommend needed

  16. Lax oversight leaves surgery center regulators and patients in the dark. | PSNet

    psnet.ahrq.gov/issue/lax-oversight-leaves-surgery-center-regulators-and-patients-dark
    May 17, 2017 - High-profile failures during office-based procedures have raised awareness of the potential safety hazards … Enhanced transparency regarding those failures can enable informed patient decision-making when choosing

  17. Incidents during out-of-hospital patient transportation. | PSNet

    psnet.ahrq.gov/issue/incidents-during-out-hospital-patient-transportation
    March 23, 2011 - They found that 91% of reported failures were preventable and conclude that incident monitoring is an … Improving patient safety governance and systems through learning from successes and failures

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38243/psn-pdf
    November 26, 2008 - https://psnet.ahrq.gov/issue/impact-preoperative-briefings-operating-room-delays Communication failures … issue/impact-preoperative-briefings-operating-room-delays https://psnet.ahrq.gov/issue/communication-failures-operating-room-observational-classification-recurrent-types-and

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39753/psn-pdf
    September 28, 2016 - psnet.ahrq.gov/issue/nursing-care-quality-and-adverse-events-us-hospitals Interruptions and other work system failures … interruptions-and-distractions-healthcare-review-and-reappraisal https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing

  20. Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery. | PSNet

    psnet.ahrq.gov/issue/locating-errors-through-networked-surveillance-multimethod-approach-peer-assessment-hazard
    May 24, 2012 - 22, 2017 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
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