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Showing results for "failures".

401. 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

402. 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

403. Medical Liability: New Ideals for Making the System Work Better for Patients. | PSNet
     psnet.ahrq.gov/issue/medical-liability-new-ideals-making-system-work-better-patients
     May 18, 2011 - liability system to more effectively help patients, families, and physicians who have been affected by failures … More Related Resources A System in Need of Repair: Addressing Organizational Failures

404. Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition. | PSNet
     psnet.ahrq.gov/issue/durasal-durezol-mix-illustrates-how-dangerous-product-problems-persist-long-after-recognition
     June 10, 2018 - This newsletter article reveals system failures that contribute to continued drug name confusion , even … June 10, 2018 Multiple latent failures align to allow a serious drug interaction to harm

405. How communications issues between doctors and nurses can affect your health. | PSNet
     psnet.ahrq.gov/issue/how-communications-issues-between-doctors-and-nurses-can-affect-your-health
     September 28, 2016 - Communication failures in health care routinely challenge patient safety. … January 20, 2020 Using incident reports to assess communication failures and patient

406. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - Unlike active failures, which are difficult to predict, latent conditions can be identified and remedied … The learning lab also identified 10 precarious events (active failures) that were the result of JACHO … Errors in health care, like human failures in any other sphere, are not just isolated causes; they are … Advances in Patient Safety: Vol. 2 430 Active failures Operative/postop complications/infections … This will result in reducing the latent conditions and active failures that lead to error.

407. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - Background: Reviews of recent research-related fatalities have demonstrated that clinical research system failures … : Collecting research unit-specific information on potential safety concerns could identify system failures … Typically the same system failures that might have resulted in an injury also are present in a near … However, these latent failures serve as “holes” in the usual safety mechanisms. … Other novel methods to identify and mange potential system failures in clinical research need to be

408. 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

409. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45375/psn-pdf
     September 27, 2016 - association-web-based-handoff-tool-rates-medical-errors Handoffs have been associated with adverse clinical events, largely due to communication failures … statistically significant decrease in the rate of medical errors, particularly errors caused by communication failures

410. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36909/psn-pdf
     January 05, 2017 - medical-team-training-applying-crew-resource-management-veterans-health- administration Communication failures … medical-team-training-applying-crew-resource-management-veterans-health-administration https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

411. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - that 87 percent of residents recalled at least one adverse event specifically related to communication failures … frequent task switching while processing large volumes of dynamic clinical information, and both cognitive failures … and system-based failures, all of which can lead to diagnostic errors. 60 Although substantial efforts

412. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - that 87 percent of residents recalled at least one adverse event specifically related to communication failures … frequent task switching while processing large volumes of dynamic clinical information, and both cognitive failures … and system-based failures, all of which can lead to diagnostic errors. 60 Although substantial efforts

413. Diagnostic Safety as a Challenge for Healthcare Leadership | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-1.html
     June 01, 2021 - and contribute to death for up to 80,000 patients in U.S. hospitals annually. 1 Evidence suggests failures … Location and Impact of Diagnostic Failures Balogh EP, Miller BT, Ball JR, eds. … Accessed June 1, 2021. 2015 CRICO Strategies National CBS Report: Malpractice Risks in Communication Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

414. 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

415. Safety culture in cardiac surgical teams: data from five programs and national surgical comparison. | PSNet
     psnet.ahrq.gov/issue/safety-culture-cardiac-surgical-teams-data-five-programs-and-national-surgical-comparison
     May 24, 2012 - 25, 2010 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

416. 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

417. 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

418. 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

419. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37290/psn-pdf
     February 15, 2011 - distinctive features of errors involving trainees, including teamwork and communication breakdowns, failures … medical-errors-involving-trainees-study-closed-malpractice-claims-5-insurers https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

420. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46652/psn-pdf
     July 14, 2018 - effects-crew-resource-management-teamwork-and-safety-climate-veterans- health-administration Communication failures … effects-crew-resource-management-teamwork-and-safety-climate-veterans-health-administration https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps