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Total Results: over 10,000 records

Showing results for "failures".

461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49814/psn-pdf
     December 01, 2017 - web-mm/miscommunication-or-leads-anticoagulation-mishap As highlighted by this case, communication failures … In one study exploring OR communication failures, researchers found that they were present in approximately … optimal safety culture is challenging: no single intervention can address all communication-related failures … Communication failures in the operating room: an observational classification of recurrent types and … Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186-194.

462. Cardio-HIT Phase II - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r18hs017160-kmetik-final-report-2009.pdf
     January 01, 2009 - study designed to investigate the prevalence and patterns of rates of exceptions, apparent quality failures … The calculation was performed separately on the number of measure failures and the number of exceptions … of identified failures that were true failures was within 5% of the same proportion among the entire … For these measures, quality failures would have been overestimated were reporting of exceptions not … Our finding that approximately 75% of cases considered apparent quality failures by automatic query

463. Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice. | PSNet
     psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line
     May 24, 2016 - From the Same Author(s) Work Design Drivers of Organizational Learning about Operational Failures … July 8, 2016 Work Design Drivers of Organizational Learning about Operational Failures

464. High reliability: excellent care every time. | PSNet
     psnet.ahrq.gov/issue/high-reliability-excellent-care-every-time
     July 19, 2018 - June 10, 2018 Reducing interdisciplinary communication failures through secure text messaging … August 12, 2015 Inquiry into reporter's death finds multiple failures in care.

465. Using HFMEA to assess potential for patient harm from tubing misconnections. | PSNet
     psnet.ahrq.gov/issue/using-hfmea-assess-potential-patient-harm-tubing-misconnections
     April 19, 2013 - October 12, 2022 Impacts of operational failures on primary care physicians' work: a … November 16, 2022 Preventing adverse events caused by emergency electrical power system failures

466. Application of failure mode and effect analysis in a radiology department. | PSNet
     psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department
     October 13, 2010 - August 10, 2022 Preventing and mitigating radiology system failures: a guide to disaster … July 1, 2009 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

467. Failure mode and effects analysis: a comparison of two common risk prioritisation methods. | PSNet
     psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-comparison-two-common-risk-prioritisation-methods
     September 09, 2015 - August 31, 2022 Reducing failures in daily medical practice: healthcare failure mode … April 24, 2018 Preventing blood transfusion failures: FMEA, an effective assessment method

468. Governing the surgical count through communication interactions: implications for patient safety. | PSNet
     psnet.ahrq.gov/issue/governing-surgical-count-through-communication-interactions-implications-patient-safety
     November 06, 2015 - RIS Download Citation Related Resources From the Same Author(s) Failures … October 11, 2023 Operational failures detected by frontline acute care nurses.

469. Management of the difficult airway: a closed claims analysis. | PSNet
     psnet.ahrq.gov/issue/management-difficult-airway-closed-claims-analysis
     July 13, 2010 - July 13, 2010 Communication failures contributing to patient injury in anaesthesia malpractice … February 8, 2023 Communication failures contributing to patient injury in anaesthesia

470. Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults. | PSNet
     psnet.ahrq.gov/issue/usability-and-feasibility-consumer-facing-technology-reduce-unsafe-medication-use-older
     February 17, 2011 - Same Author(s) Effect of reducing interns' weekly work hours on sleep and attentional failures … March 6, 2019 Multiple latent failures align to allow a serious drug interaction to harm

471. Factors influencing perioperative nurses' error reporting preferences. | PSNet
     psnet.ahrq.gov/issue/factors-influencing-perioperative-nurses-error-reporting-preferences
     June 23, 2010 - December 8, 2010 Communication failures in the operating room: an observational classification … August 14, 2019 Using incident reports to assess communication failures and patient outcomes

472. Provider perspectives on partnering with parents of hospitalized children to improve safety. | PSNet
     psnet.ahrq.gov/issue/provider-perspectives-partnering-parents-hospitalized-children-improve-safety
     November 30, 2016 - November 30, 2016 Operational failures detected by frontline acute care nurses. … July 5, 2017 Participating in a multisite study exploring operational failures encountered

473. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. | PSNet
     psnet.ahrq.gov/issue/protecting-patients-unsafe-system-etiology-and-recovery-intraoperative-deviations-care
     October 19, 2012 - Related Resources From the Same Author(s) Deconstructing intraoperative communication failures … July 2, 2014 Failures in communication and information transfer across the surgical care

474. Practical challenges of introducing WHO surgical checklist: UK pilot experience. | PSNet
     psnet.ahrq.gov/issue/practical-challenges-introducing-who-surgical-checklist-uk-pilot-experience
     September 26, 2012 - RIS Download Citation Related Resources From the Same Author(s) Failures … May 6, 2015 An observational study of the frequency, severity, and etiology of failures

475. Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida. | PSNet
     psnet.ahrq.gov/issue/quality-care-cranial-implant-surgeries-james-haley-va-medical-center-tampa-florida
     June 13, 2012 - Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures … July 27, 2022 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

476. Checking the lists: a systematic review of electronic checklist use in health care. | PSNet
     psnet.ahrq.gov/issue/checking-lists-systematic-review-electronic-checklist-use-health-care
     August 08, 2018 - Related Resources From the Same Author(s) Identification and characterization of failures … July 17, 2019 Reducing interdisciplinary communication failures through secure text messaging

477. Safety through redundancy: a case study of in-hospital patient transfers. | PSNet
     psnet.ahrq.gov/issue/safety-through-redundancy-case-study-hospital-patient-transfers
     November 03, 2015 - November 3, 2015 Syndromic surveillance for health information system failures: a feasibility … December 21, 2014 A systematic review of failures in handoff communication during intrahospital

478. Last orders: follow-up of tests ordered on the day of hospital discharge. | PSNet
     psnet.ahrq.gov/issue/last-orders-follow-tests-ordered-day-hospital-discharge
     November 03, 2015 - November 3, 2015 Syndromic surveillance for health information system failures: a feasibility … November 2, 2010 A systematic review of failures in handoff communication during intrahospital

479. Automated identification of extreme-risk events in clinical incident reports. | PSNet
     psnet.ahrq.gov/issue/automated-identification-extreme-risk-events-clinical-incident-reports
     November 03, 2015 - November 3, 2015 Syndromic surveillance for health information system failures: a feasibility … November 2, 2010 A systematic review of failures in handoff communication during intrahospital

480. Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices. | PSNet
     psnet.ahrq.gov/issue/nurses-perceived-skills-and-attitudes-about-updated-safety-concepts-impact-medication
     January 03, 2017 - September 27, 2017 Impact of interruptions, distractions, and cognitive load on procedure failures … July 2, 2014 Identifying the latent failures underpinning medication administration errors