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Total Results: over 10,000 records

Showing results for "failures".

421. 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

422. 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

423. Patient Safety Authority. | PSNet
     psnet.ahrq.gov/issue/patient-safety-authority
     October 07, 2020 - Pennsylvania Copy Citation Related Resources From the Same Author(s) Process failures … October 7, 2020 Patient harm resulting from medication reconciliation process failures

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37543/psn-pdf
     March 03, 2011 - Although extended shifts were associated with self-reported attentional failures in one study, other … /psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39523/psn-pdf
     September 26, 2016 - administration and discovered that each interruption was associated with a 12.1% increase in procedural failures … association-interruptions-increased-risk-and-severity-medication-administration-errors https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49415/psn-pdf
     September 01, 2003 - 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 … 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.

427. Sensemakingnotes (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
     August 08, 2012 - Active failures are also called human error. … Active failures are categorized in three main types: skill-based, rule-based, and knowledge-based. · … 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.

428. PowerPoint Presentation (ppt file)
     digital.ahrq.gov/sites/default/files/docs/page/Dixie%20Baker1.ppt
     June 09, 2005 - Avoid/eliminate single-point failures – distributed architectures can tolerate failure more easily than … Expect failures. … application-transparent features to detect faults, failover to redundant components, and recover from infrastructure failures

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40092/psn-pdf
     December 22, 2010 - value-adding-verbal-report-written-handoffs-early-readmission-following- prolonged-respiratory Teamwork and communication failures … Intensive care units (ICU) have demonstrated the impact of different strategies to address these failures

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43869/psn-pdf
     November 03, 2015 - The researchers found that while most events were technical failures, incidents involving human errors … Technical failures affecting 10 or more patients accounted for nearly 25% of events and were more likely

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38116/psn-pdf
     February 18, 2011 - /psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures … /psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures

432. Anatomy and pathophysiology of errors occurring in clinical radiology practice. | PSNet
     psnet.ahrq.gov/issue/anatomy-and-pathophysiology-errors-occurring-clinical-radiology-practice
     February 01, 2011 - diagnostic errors in radiology and describes a classification scheme to identify and prevent potential failures … 14, 2011 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

433. Veterans Accountability Improvement Act. | PSNet
     psnet.ahrq.gov/issue/veterans-accountability-improvement-act
     March 25, 2020 - March 25, 2020 A System in Need of Repair: Addressing Organizational Failures of the … May 4, 2022 Pathology Oversight Failures at the Veterans Health Care System of the Ozarks

434. How reliable are clinical systems in the UK NHS? A study of seven NHS organisations. | PSNet
     psnet.ahrq.gov/issue/how-reliable-are-clinical-systems-uk-nhs-study-seven-nhs-organisations
     November 26, 2008 - February 8, 2017 Identifying systems failures in the pathway to a catastrophic event: … August 12, 2014 Surgical technology and operating-room safety failures: a systematic … August 13, 2013 An observational study of the frequency, severity, and etiology of failures

435. Final Progress Report: Older adult safety while receiving home health services after hospital discharge (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/22916-Arbaje-report.pdf
     January 15, 2018 - 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

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37387/psn-pdf
     January 10, 2017 - management (CRM) methods to health care settings has been driven by noted teamwork and communication failures … potential-improved-teamwork-reduce-medical-errors-emergency-department https://psnet.ahrq.gov/issue/communication-failures-insidious-contributor-medical-mishaps

437. Clear liquids may place patients at risk. | PSNet
     psnet.ahrq.gov/issue/clear-liquids-may-place-patients-risk
     May 19, 2021 - November 11, 2020 Process failures that increase the risk of infection through respiratory … October 7, 2020 Patient harm resulting from medication reconciliation process failures

438. The Diagnosis of Ectopic Pregnancy. | PSNet
     psnet.ahrq.gov/issue/diagnosis-ectopic-pregnancy
     April 26, 2023 - March 1, 2023 Clinical Investigation Booking Systems Failures: Written Communications … June 14, 2023 Clinical Investigation Booking Systems Failures: Written Communications

439. Patients with low health literacy make more errors interpreting instructions and warnings. | PSNet
     psnet.ahrq.gov/issue/patients-low-health-literacy-make-more-errors-interpreting-instructions-and-warnings
     May 03, 2023 - , 2023 Patient death tied to lack of proper escalation process for barcode scanning failures … March 14, 2023 Latent and active failures perfectly align to allow a preventable adverse

440. Science and patient safety. | PSNet
     psnet.ahrq.gov/issue/science-and-patient-safety
     July 19, 2019 - July 15, 2015 Surgical technology and operating-room safety failures: a systematic review … April 12, 2011 An observational study of the frequency, severity, and etiology of failures