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Showing results for "failures".

  1. VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout. | PSNet

    psnet.ahrq.gov/issue/va-pauses-16b-oracle-cerner-ehr-deployments-indefinitely-address-error-ridden-early-rollout
    September 14, 2022 - May 3, 2023 Clinical Investigation Booking Systems Failures: Written Communications in … Improve Management of Sepsis May 31, 2023 Clinical Investigation Booking Systems Failures

  2. 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

  3. Risk Assessment | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/risk
    January 01, 2023 - Description Failure mode and effects analysis (FMEA) is a method that attempts to identify all possible failures … Analysis Description Fault tree analyses (FTAs) study specific system, process, or product failures

  4. 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

  5. No Slide Title (ppt file)

    digital.ahrq.gov/sites/default/files/docs/implementation/REILING_8_V.ppt
    January 01, 2005 - Source: To Err is Human, Institute of Medicine Active Failures An error that occurs at the level … of 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

  6. 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

  7. 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

  8. A brief analysis of telemetry–related events. | PSNet

    psnet.ahrq.gov/issue/brief-analysis-telemetry-related-events
    October 07, 2020 - Copy Citation Related Resources From the Same Author(s) Process failures … September 19, 2016 Patient harm resulting from medication reconciliation process failures

  9. 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

  10. 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.

  11. 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

  12. 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

  13. Unprofessional Behavior Leads to Complications. | PSNet

    psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications
    June 03, 2020 - 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

  14. Teaching Clinical Reasoning. | PSNet

    psnet.ahrq.gov/issue/teaching-clinical-reasoning
    August 20, 2018 - February 15, 2010 The role of automation in complex system failures. … Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures

  15. An Amendment of the Medical Care Availability and Reduction of Error (Mcare) Act. | PSNet

    psnet.ahrq.gov/issue/amendment-medical-care-availability-and-reduction-error-mcare-act
    June 03, 2009 - June 27, 2007 Process failures that increase the risk of infection through respiratory … December 9, 2020 Patient harm resulting from medication reconciliation process failures

  16. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects

    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - Failure Mode and Effects Analysis - Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … 6 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Examples of Defects or Failures … Sensemaking and Learn From Defects Sensemaking and Learn From Defects share several common themes Defects or failures

  17. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects

    www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - Failure Mode and Effects Analysis - Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … 6 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Examples of Defects or Failures … Sensemaking and Learn From Defects Sensemaking and Learn From Defects share several common themes Defects or failures

  18. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects

    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - Failure Mode and Effects Analysis - Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … 6 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Examples of Defects or Failures … Sensemaking and Learn From Defects Sensemaking and Learn From Defects share several common themes Defects or failures

  19. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects

    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - Failure Mode and Effects Analysis - Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … 6 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Examples of Defects or Failures … Sensemaking and Learn From Defects Sensemaking and Learn From Defects share several common themes Defects or failures

  20. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects

    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - Failure Mode and Effects Analysis - Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … 6 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Examples of Defects or Failures … Sensemaking and Learn From Defects Sensemaking and Learn From Defects share several common themes Defects or failures
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