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Showing results for "failures".

381. 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

382. 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

383. 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

384. 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.

385. 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.

386. 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

387. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/identify/notes.html
     December 01, 2012 - Examples of Defects or Failures That Affect Patient Safety Slide 9. … Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … 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.

388. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     preventiveservices.ahrq.gov/hai/cusp/modules/identify/notes.html
     December 01, 2012 - Examples of Defects or Failures That Affect Patient Safety Slide 9. … Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … 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.

389. 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

390. 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

391. 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

392. 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

393. Is health care getting safer? | PSNet
     psnet.ahrq.gov/issue/health-care-getting-safer
     December 14, 2016 - February 8, 2017 Identifying systems failures in the pathway to a catastrophic event: … March 4, 2011 Surgical technology and operating-room safety failures: a systematic review … August 13, 2013 An observational study of the frequency, severity, and etiology of failures

394. Engineering the system of communication for safer surgery. | PSNet
     psnet.ahrq.gov/issue/engineering-system-communication-safer-surgery
     January 18, 2013 - the Same Author(s) An observational study of the frequency, severity, and etiology of failures … August 11, 2010 Failures in communication and information transfer across the surgical … September 9, 2011 Surgical technology and operating-room safety failures: a systematic

395. Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities. | PSNet
     psnet.ahrq.gov/issue/evaluation-registered-nurse-competency-processes-veterans-health-administration-facilities
     April 26, 2006 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … September 5, 2012 Identifying the latent failures underpinning medication administration

396. 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

397. 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

398. 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

399. 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

400. 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