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Showing results for "failures".

41. Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals. | PSNet
    psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events
    October 07, 2020 - Study Patient harm resulting from medication reconciliation process failures: a study … Patient harm resulting from medication reconciliation process failures: a study of serious events reported … The most common process failures contributing to patient harm occurred during order entry/transcription … Patient harm resulting from medication reconciliation process failures: a study of serious events reported … Download Citation Related Resources From the Same Author(s) Process failures

42. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
    June 01, 2021 - an opportunity to prevent the same problem from occurring again System design Can result in “latent” failures … Human behavior Can result in “active” failures 3 Changing the System 3 System Failures System failures … Errors that occur because of individual actions Generally readily apparent Examples of active failures … Organizational Influences – Latent failures Unsafe acts – Active failures Unsafe supervision – Latent … 17 Changing the System 17 Review Consider system/active failures which may have led to the problem

43. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60325/psn-pdf
    May 13, 2020 - Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis … Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis … https://psnet.ahrq.gov/issue/impacts-operational-failures-primary-care-physicians-work-critical-interpretive … - synthesis This review synthesized research exploring how operational failures (e.g., distractions … The authors suggest that future research focus on which operational failures have the highest impact

44. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/131-ss-swiss-cheese.pptx
    April 01, 2025 - PowerPoint Presentation Learning From Defects: Applying the “Swiss Cheese Model” of System Failures … Apply a patient example to discover system failures. … : Swiss Cheese Model1 active failure latent failures Adapted from: Reason, J. … include latent and active failures. … The impact of operational failures on hospital nurses and their patients.

45. Failures in the respectful care of critically ill patients. | PSNet
    psnet.ahrq.gov/issue/failures-respectful-care-critically-ill-patients
    December 19, 2018 - Study Failures in the respectful care of critically ill patients. … Failures in the Respectful Care of Critically Ill Patients. … Failures in the Respectful Care of Critically Ill Patients.

46. Failures in communication and information transfer across the surgical care pathway: interview study. | PSNet
    psnet.ahrq.gov/issue/failures-communication-and-information-transfer-across-surgical-care-pathway-interview-study
    August 09, 2013 - Study Failures in communication and information transfer across the surgical care … Failures in communication and information transfer across the surgical care pathway: interview study. … This qualitative study found considerable evidence for communication failures between clinicians at … Failures in communication and information transfer across the surgical care pathway: interview study. … July 6, 2012 An observational study of the frequency, severity, and etiology of failures

47. When things go wrong: how health care organizations deal with major failures. | PSNet
    psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures
    March 13, 2013 - Classic When things go wrong: how health care organizations deal with major failures … When things go wrong: how health care organizations deal with major failures. … The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the … reporting and investigation mechanisms, and greater transparency in both reporting and responding to major failures … When things go wrong: how health care organizations deal with major failures.

48. Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography. | PSNet
    psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures-detect-foreign
    April 03, 2017 - Commentary Profiles in patient safety: misplaced femoral line guidewire and multiple failures … Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures to Detect the Foreign … report, the authors discuss a series of errors and illustrate the concepts of active  and latent failures … Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures to Detect the Foreign … Diagnoses of Cancer July 31, 2023 Preventing and mitigating radiology system failures

49. Preventing and mitigating radiology system failures: a guide to disaster planning. | PSNet
    psnet.ahrq.gov/issue/preventing-and-mitigating-radiology-system-failures-guide-disaster-planning
    November 23, 2016 - Commentary Preventing and mitigating radiology system failures: a guide to disaster … Preventing and mitigating radiology system failures: a guide to disaster planning. … hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures … Preventing and mitigating radiology system failures: a guide to disaster planning. … February 9, 2011 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

50. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/836852/psn-pdf
    April 06, 2022 - Frequency and nature of communication and handoff failures in medical malpractice claims. … Frequency and nature of communication and handoff failures in medical malpractice claims. … https://psnet.ahrq.gov/issue/frequency-and-nature-communication-and-handoff-failures-medical- malpractice-claims … play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures … https://psnet.ahrq.gov/issue/malpractice-risks-communication-failures-2015-annual-benchmarking-report

51. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. | PSNet
    psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
    November 16, 2022 - The model discussed focuses on two types of failures, which share equal importance in analysis but distinguish … The first, active failures , consists of mistakes made by providers in the delivery of care. … The second, latent failures , represents flaws in the systems of care. … The authors use a case example in anesthesia to illustrate how searching for active failures alone fails … analysis of past disasters has offered a useful model to differentiate provider from organizational failures

52. Frequency and nature of communication and handoff failures in medical malpractice claims. | PSNet
    psnet.ahrq.gov/issue/frequency-and-nature-communication-and-handoff-failures-medical-malpractice-claims
    June 22, 2022 - Study Frequency and nature of communication and handoff failures in medical malpractice … Frequency and nature of communication and handoff failures in medical malpractice claims. … play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures … Frequency and nature of communication and handoff failures in medical malpractice claims.

53. A systematic review of failures in handoff communication during intrahospital transfers. | PSNet
    psnet.ahrq.gov/issue/systematic-review-failures-handoff-communication-during-intrahospital-transfers
    November 03, 2015 - Review A systematic review of failures in handoff communication during intrahospital … A systematic review of failures in handoff communication during intrahospital transfers. … Communication failures at the time of patient handoffs have been frequently implicated in adverse … A systematic review of failures in handoff communication during intrahospital transfers. … November 3, 2015 Syndromic surveillance for health information system failures: a feasibility

54. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60987/psn-pdf
    October 07, 2020 - Process failures that increase the risk of infection through respiratory droplets: a study of patient … Process failures that increase the risk of infection through respiratory droplets: a study of patient … https://psnet.ahrq.gov/issue/process-failures-increase-risk-infection-through-respiratory-droplets-study … - patient-safety In an effort to identify process failures related to infectious disease spread in … The analysis identified several process failures, most commonly involving the testing or processing

55. Effect of reducing interns' weekly work hours on sleep and attentional failures. | PSNet
    psnet.ahrq.gov/issue/effect-reducing-interns-weekly-work-hours-sleep-and-attentional-failures
    January 10, 2017 - Study Effect of reducing interns' weekly work hours on sleep and attentional failures … Effect of reducing interns' weekly work hours on sleep and attentional failures. … that limiting intern work hours to less than 80 hours per week led to more sleep and less attentional failures … least one electrooculophaphy-derived slow eye movement while at work, a validated marker for attention failures … Effect of reducing interns' weekly work hours on sleep and attentional failures.

56. Systemic failures in nursing home care--a scoping study. | PSNet
    psnet.ahrq.gov/issue/systemic-failures-nursing-home-care-scoping-study
    July 17, 2013 - Review Systemic failures in nursing home care--a scoping study. … Systemic failures in nursing home care—A scoping study. … Systemic failures in nursing home care—A scoping study.

57. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73657/psn-pdf
    September 01, 2021 - Communication failures contributing to patient injury in anaesthesia malpractice claims. … Communication failures contributing to patient injury in anaesthesia malpractice claims. … https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice … https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims … https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims

58. 130-Ss-Swiss-Cheese-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
    April 01, 2025 - To ensure a defect never happens again, failures should be viewed from a systems lens to improve the … the “Swiss cheese model” to illustrate how system failures occur and why some failures lead to an event … Active failures occur when an “operator” performs an unsafe action that leads to an event. … active failures. … In other words, active failures are the adverse events the team thinks about and attempts to avoid.

59. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73417/psn-pdf
    June 23, 2021 - Classification of failures in the perception of conversational agents (CAs) and their implications on … Classification of failures in the perception of conversational agents (CAs) and their implications on … https://psnet.ahrq.gov/issue/classification-failures-perception-conversational-agents-cas-and-their- … Investigators used these CAs to detect errors and failures in calculating correct insulin doses. … Potential failures must be considered before deployment of CAs in safety-critical environments.

60. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47921/psn-pdf
    June 18, 2019 - Using incident reports to assess communication failures and patient outcomes. … Using Incident Reports to Assess Communication Failures and Patient Outcomes. … https://psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes … Communication failures are a common underlying factor in adverse events. … /issue/communication-failures-operating-room-observational-classification-recurrent-types-and https:/