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Showing results for "failures".

361. 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

362. A Patient-Centered Perspective on Medication Use: Self-Management Versus Adherence | Agency for Healthcare Research and Quality
     www.ahrq.gov/chain/research-tools/featured-certs/patient-centered-perspective.html
     March 01, 2017 - Adherence, Part 2 Part 2 (YouTube) summarizes the problem of how regimens both cause and cure body "failures … " and how such failures can cause poor performance, loss of self, and suffering.

363. Final Progress Report: Improving ED Quality and Safety by Enhancing Operations and Quality Management (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/khare-report.pdf
     January 01, 2024 - Of the 12 high-risk failures, 58% occurred between ECG and catheterization laboratory activation. … An FMECA elicits information about any failures for each step in a process including the underlying … An FMECA also permitted ranking of failures from high to low risk. … The failures were then “binned” into high-, medium-, and low-risk bins. … To the degree possible, both hospitals tried to work on similar failures.

364. 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.

365. 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

366. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-from-defects-slides.html
     May 01, 2017 - 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 Medication … Defects or failures are clinical or operational events that you do not want to happen again.

367. 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.

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39975/psn-pdf
     March 03, 2011 - https://psnet.ahrq.gov/issue/communication-failure-operating-room Communication failures are a well-characterized … this study, implementation of a teamwork training program was associated with fewer communication failures

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47418/psn-pdf
     September 19, 2018 - /issue/how-communications-issues-between-doctors-and-nurses-can-affect-your- health Communication failures … how-communications-issues-between-doctors-and-nurses-can-affect-your-health https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45021/psn-pdf
     April 06, 2016 - scandal-sentinel-event-recognizing-hidden-cost-quality-trade-offs Latent factors are known to contribute to system-level failures … meet performance targets and insufficient safety culture led to unintended consequences and system failures

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43550/psn-pdf
     October 15, 2014 - medical records (EMRs), they will need contingency plans to ensure patient safety in the event of system failures … survey of 50 institutions with fully integrated EMRs found that nearly all had experienced unexpected failures

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45438/psn-pdf
     September 07, 2016 - 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

373. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47193/psn-pdf
     September 05, 2018 - , Recommendation (SBAR) is a mnemonic used to structure information sharing to avoid communication failures … implementing-sbar-across-large-multihospital-health-system https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

374. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34667/psn-pdf
     January 17, 2018 - authors (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

375. 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

376. 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

377. 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

378. Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study. | PSNet
     psnet.ahrq.gov/issue/hospital-acquired-functional-decline-and-clinical-outcomes-older-cardiac-surgical-patients
     February 06, 2019 - 19, 2021 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

379. 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

380. Decimal numbers and safe interpretation of clinical pathology results. | PSNet
     psnet.ahrq.gov/issue/decimal-numbers-and-safe-interpretation-clinical-pathology-results
     July 16, 2014 - January 12, 2011 Operational failures in general practice: a consensus-building study … May 22, 2024 Impacts of operational failures on primary care physicians' work: a critical … November 16, 2022 Operational failures detected by frontline acute care nurses.