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Showing results for "failures".

  1. The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. | PSNet

    psnet.ahrq.gov/issue/effects-leadership-self-worth-inclusion-trust-and-psychological-safety-medical-error
    March 30, 2022 - Study The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. Citation Text: Brimhall KC, Tsai C-Y, Eckardt R, et al. The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. …

  2. Executive Summary | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/vtguide/guidesum.html
    March 01, 2016 - Preventing Hospital-Associated Venous Thromboembolism Executive Summary Previous Page Next Page Table of Contents Preventing Hospital-Associated Venous Thromboembolism Preface Executive Summary Chapter 1. The Framework for Improvement Chapter 2. Analyze Care Delivery Chapter 3. Outline the…

  3. Mollon B et al. 2009 "Features predicting the success of computerized decision support for prescribing: a systematic review of randomized controlled trials." | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/mollon-b-et-al-2009
    January 01, 2009 - Mollon B et al. 2009 "Features predicting the success of computerized decision support for prescribing: a systematic review of randomized controlled trials." Reference Mollon B, Chong JJR, Holbrook AM, et al. Features predicting the success of computerized decision support for prescribing: a systemati…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36250/psn-pdf
    February 06, 2019 - Resilience Engineering: Concepts and Precepts. February 6, 2019 Hollnagel E, Woods DD, Leveson N. Burlington, VT: Ashgate; 2006. ISBN: 978-0754649045. https://psnet.ahrq.gov/issue/resilience-engineering-concepts-and-precepts This book explores how organizations and individuals must anticipate risk and continuously …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35075/psn-pdf
    August 24, 2005 - The Patient's Guide to Preventing Medical Errors. August 24, 2005 Bernsten KJ. Westport CT: Praeger; 2004. https://psnet.ahrq.gov/issue/patients-guide-preventing-medical-errors The author provides an introduction to issues affecting safety in health care for a consumer audience. The text is interspersed with relev…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36673/psn-pdf
    January 18, 2011 - Patient safety: honoring advanced directives. January 18, 2011 Tice MA. Patient safety: honoring advanced directives. Home Healthc Nurse. 2007;25(2):79-81. https://psnet.ahrq.gov/issue/patient-safety-honoring-advanced-directives The author discusses why failure to follow an advance directive should be considered a …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49413/psn-pdf
    September 01, 2003 - Did We Forget Something? September 1, 2003 Gibbs VC. Did We Forget Something? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/did-we-forget-something The Case A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially attributed to ventilator-associated pneumo…

  8. Facts and Figures Exhibit 2.1

    hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit2_1.jsp
    January 01, 2007 - Facts and Figures Exhibit 2.1 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49507/psn-pdf
    April 01, 2006 - Is the "Surgical Personality" a Threat to Patient Safety? April 1, 2006 Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety? PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety Case Objectives Describe the myth of the "surgical personality" Identify featu…

  10. Final Progress Report: The Role of Collective Mindfulness in Delivering Reliable and Safe Perioperative Care to Neonates (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/france-report.pdf
    January 01, 2024 - Identification of systems failures in successful paediatric cardiac surgery. Ergonomics. … The contribution of latent human failures to the breakdown of complex systems. … Failures without errors: quantification of context in HRA. … An analysis of major errors and equipment failures in anesthesia management: Considerations for prevention

  11. Improving Healthcare Safety by Enhancing Care Coordination (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-care-coordination.pdf
    June 30, 2025 - report was not available, but one resulting publication characterized discharge dilemmas as system failures … High criticality failures (e.g., failure to detect large vessel occlusion, failure to use screening … Preliminary data indicated that failures were correlated with gaps in processes. … The intervention includes a package of services to minimize discharge failures—a process called Re-Engineered

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40466/psn-pdf
    May 18, 2011 - Making FMEA work for you. May 18, 2011 Reams J. Making FMEA work for you. Nurs Manage. 2011;42(5):18-20. doi:10.1097/01.NUMA.0000396500.05462.6e. https://psnet.ahrq.gov/issue/making-fmea-work-you This commentary describes failure mode and effects analysis and discusses how it can improve patient safety. https://…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39744/psn-pdf
    September 13, 2010 - Are you using checklists? Check! September 13, 2010 McNellis B, AAPA QCC of the. Are you using checklists? Check!. JAAPA. 2010;23(7):24-6, 31. https://psnet.ahrq.gov/issue/are-you-using-checklists-check This piece emphasizes how checklists can be effective tools to prevent medical error and reduce communication fa…

  14. Patient medication issues code book | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/ahrq-funded-project-resources-archives/patient-medication-issues-code
    January 01, 2023 - Patient medication issues code book Description Qualitative / Content Analysis study code book example. Used to code responses from a patient to a series of issues surrounding medication management. Document Type Logging Tool Document Source Tailored DVD to Improve M…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60269/psn-pdf
    April 29, 2020 - Identifying Risks to Patient Safety In the presented case, there were undoubtedly multiple failures

  16. Diagnostic Error | PSNet

    psnet.ahrq.gov/curated-library/diagnostic-error
    September 14, 2025 - with clinicians, poor communication between clinicians and patients or between clinicians, and systems failures

  17. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
    October 28, 2020 - WebM&M Cases Delay in Malignancy Diagnosis Reflects Systemic Failures

  18. Mobility Lost in the ICU | PSNet

    psnet.ahrq.gov/web-mm/mobility-lost-icu
    August 01, 2018 - SPOTLIGHT CASE Mobility Lost in the ICU Citation Text: Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

  19. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers | PSNet

    psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
    January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers Citation Text: Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

  20. Module 1: Overview | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod1-slides.html
    February 01, 2023 - Module 1: Overview Preventing CAUTI in the ICU Setting Slide Presentation Slide 1 AHRQ Safety Program for Reducing CAUTI in Hospitals Preventing CAUTI in the ICU Setting Module 1: Overview AHRQ Pub. No. 15-0073-4-EF September 2015 Slide 2 Learning Objectives At the end of this educational…
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