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Total Results: over 10,000 records

Showing results for "failures".

421. Concurrent and Overlapping Surgeries: Additional Measures Warranted. | PSNet
     psnet.ahrq.gov/issue/concurrent-and-overlapping-surgeries-additional-measures-warranted
     August 17, 2022 - Resources From the Same Author(s) A System in Need of Repair: Addressing Organizational Failures … More Related Resources A System in Need of Repair: Addressing Organizational Failures

422. Implement strategies to prevent persistent medication errors and hazards. | PSNet
     psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards
     March 14, 2023 - May 3, 2023 Latent and active failures perfectly align to allow a preventable adverse … November 1, 2023 Latent and active failures perfectly align to allow a preventable adverse

423. Unprofessional Behavior Leads to Complications. | PSNet
     psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications
     October 31, 2023 - June 3, 2020 Closing the loop on test results to reduce communication failures: a rapid … March 31, 2021 Using trainee failures to enhance learning: a qualitative study of pediatric

424. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy. | PSNet
     psnet.ahrq.gov/issue/current-state-diagnostic-safety-implications-research-practice-and-policy
     August 07, 2024 - August 9, 2024 Operational failures in general practice: a consensus-building study on … August 16, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

425. The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide. | PSNet
     psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide
     January 09, 2025 - 2022 Health literacy-related safety events: a qualitative study of health literacy failures … September 30, 2020 Multiple latent failures align to allow a serious drug interaction

426. Examining the Status of VA’s Electronic Health Record Modernization Program. | PSNet
     psnet.ahrq.gov/issue/examining-status-vas-electronic-health-record-modernization-program
     November 10, 2021 - November 10, 2021 A System in Need of Repair: Addressing Organizational Failures of the … October 12, 2022 A System in Need of Repair: Addressing Organizational Failures of the

427. Assessing medication safety in settings not designated solely for pediatric patients. | PSNet
     psnet.ahrq.gov/issue/assessing-medication-safety-settings-not-designated-solely-pediatric-patients
     February 01, 2023 - Copy Citation Related Resources From the Same Author(s) Latent and active failures … February 8, 2023 Latent and active failures perfectly align to allow a preventable adverse

428. Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke. | PSNet
     psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-thrombolysis-acute
     November 13, 2019 - March 1, 2023 Clinical Investigation Booking Systems Failures: Written Communications … June 14, 2023 Clinical Investigation Booking Systems Failures: Written Communications

429. Manojlovich, Milisa | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/manojlovich-milisa
     January 01, 2023 - Healthcare Provider Communication Using incident reports to assess communication failures … Using Incident Reports to Assess Communication Failures and Patient Outcomes.

430. Workarounds and Resiliency on the Front Lines of Health Care | PSNet
     psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
     August 01, 2009 - More importantly, operational failures disrupt patient care, leading to uncompleted tasks and medical … Identification of systems failures in successful paediatric cardiac surgery. … The impact of operational failures on hospital nurses and their patients. … Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41:643-662. … There's bank failures, corporate failures in the auto industry, and health care.

431. Improving reliability with root cause analysis. | PSNet
     psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis
     January 17, 2017 - 14, 2005 Profiles in patient safety: misplaced femoral line guidewire and multiple failures … July 22, 2020 Multiple latent failures align to allow a serious drug interaction to harm

432. Annual Benchmarking Report: Malpractice Risks in Surgery. | PSNet
     psnet.ahrq.gov/issue/annual-benchmarking-report-malpractice-risks-surgery
     July 18, 2018 - June 24, 2020 Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report … August 24, 2022 Communication failures contributing to patient injury in anaesthesia

433. Layout 1 (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/treatment-resistant-depression_executive.pdf
     September 01, 2011 - treatment failure are sometimes included in this group, but patients with two or more prior treatment failures … • Tier 2 evidence: studies in which patients had one or more prior treatment failures. … Although these definitions appear to be converging on a single meaning—two or more treatment failures … The number of treatment failures in the current episode should be delineated carefully. … determine whether the particular number of failures, or reaching a particular number of failures in

434. Errors in the administration of intravenous medication in Brazilian hospitals. | PSNet
     psnet.ahrq.gov/issue/errors-administration-intravenous-medication-brazilian-hospitals
     October 05, 2022 - May 30, 2018 Impact of interruptions, distractions, and cognitive load on procedure failures … September 12, 2012 Identifying the latent failures underpinning medication administration

435. Registered nurses' judgments of the classification and risk level of patient care errors. | PSNet
     psnet.ahrq.gov/issue/registered-nurses-judgments-classification-and-risk-level-patient-care-errors
     August 24, 2022 - December 1, 2011 Frequency and nature of communication and handoff failures in medical … September 12, 2012 Identifying the latent failures underpinning medication administration

436. Quantifying discharge medication reconciliation errors at 2 pediatric hospitals. | PSNet
     psnet.ahrq.gov/issue/quantifying-discharge-medication-reconciliation-errors-2-pediatric-hospitals
     October 20, 2021 - 2021 Health literacy-related safety events: a qualitative study of health literacy failures … December 21, 2017 Frequency and nature of communication and handoff failures in medical

437. ISMP updates its list of drug names with tall man (mixed case) letters based on survey results. | PSNet
     psnet.ahrq.gov/issue/ismp-updates-its-list-drug-names-tall-man-mixed-case-letters-based-survey-results
     March 14, 2023 - May 7, 2018 Latent and active failures perfectly align to allow a preventable adverse … June 10, 2018 View More Related Resources Latent and active failures

438. Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes. | PSNet
     psnet.ahrq.gov/issue/association-between-paediatric-intraoperative-anaesthesia-handover-and-adverse-postoperative
     July 21, 2021 - June 27, 2018 An observational study of postoperative handoff standardization failures … August 10, 2022 An observational study of postoperative handoff standardization failures

439. Physician engagement in malpractice risk reduction: a UPHS case study. | PSNet
     psnet.ahrq.gov/issue/physician-engagement-malpractice-risk-reduction-uphs-case-study
     June 02, 2019 - Same Author(s) Failure to debrief after critical events in anesthesia is associated with failures … July 19, 2023 Operational failures detected by frontline acute care nurses.

440. Assessment of DoD Wounded Warrior Matters: Managing Risks of Multiple Medications. | PSNet
     psnet.ahrq.gov/issue/assessment-dod-wounded-warrior-matters-managing-risks-multiple-medications
     March 16, 2022 - May 1, 2015 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures