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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39010/psn-pdf
    April 12, 2011 - Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center. April 12, 2011 McCullough JS, McKenna D, Kadidlo D, et al. Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center. Blood. 2009;114(8):1684-8. doi:10…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47062/psn-pdf
    October 13, 2018 - Latent risk assessment tool for health care leaders. October 13, 2018 Paine LA, Holzmueller CG, Elliott R, et al. Latent risk assessment tool for health care leaders. J Healthc Risk Manag. 2018;38(2):36-46. doi:10.1002/jhrm.21316. https://psnet.ahrq.gov/issue/latent-risk-assessment-tool-health-care-leaders Health …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39616/psn-pdf
    February 02, 2011 - Infection control assessment of ambulatory surgical centers. February 2, 2011 Schaefer MK, Jhung M, Dahl M, et al. Infection control assessment of ambulatory surgical centers. JAMA. 2010;303(22):2273-9. doi:10.1001/jama.2010.744. https://psnet.ahrq.gov/issue/infection-control-assessment-ambulatory-surgical-centers…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837738/psn-pdf
    July 27, 2022 - High-reliability organisation principles implemented in dentistry. July 27, 2022 Minyé HM, Benjamin EM. High-reliability organisation principles implemented in dentistry. Br Dent J. 2022;232(12):879-885. doi:10.1038/s41415-022-4354-z. https://psnet.ahrq.gov/issue/high-reliability-organisation-principles-implemente…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41896/psn-pdf
    December 12, 2012 - Bar-code verification: reducing but not eliminating medication errors. December 12, 2012 Henneman PL, Marquard J, Fisher DL, et al. Bar-code verification: reducing but not eliminating medication errors. J Nurs Adm. 2012;42(12):562-6. doi:10.1097/NNA.0b013e318274b545. https://psnet.ahrq.gov/issue/bar-code-verificat…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38968/psn-pdf
    May 04, 2014 - What went right: lessons for the intensivist from the crew of US Airways Flight 1549. May 4, 2014 Eisen LA, Savel RH. What went right: lessons for the intensivist from the crew of US Airways Flight 1549. Chest. 2009;136(3):910-917. doi:10.1378/chest.09-0377. https://psnet.ahrq.gov/issue/what-went-right-lessons-int…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73898/psn-pdf
    September 29, 2021 - A Thematic Analysis of HSIB's First 22 Investigations.  September 29, 2021 Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021. https://psnet.ahrq.gov/issue/thematic-analysis-hsibs-first-22-investigations In-depth failure investigations provide improvement insights for individuals and or…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45476/psn-pdf
    September 21, 2016 - Use of a surgical safety checklist to improve team communication. September 21, 2016 Cabral RA, Eggenberger T, Keller K, et al. Use of a surgical safety checklist to improve team communication. AORN J. 2016;104(3):206-216. doi:10.1016/j.aorn.2016.06.019. https://psnet.ahrq.gov/issue/use-surgical-safety-checklist-i…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42734/psn-pdf
    November 13, 2013 - Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee. November 13, 2013 Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348. https://psnet.ahrq.gov/issue/healthcare-inspection-emergency-department-patient-deat…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37789/psn-pdf
    June 04, 2008 - The cost of nurse-sensitive adverse events. June 4, 2008 Pappas SH. The cost of nurse-sensitive adverse events. J Nurs Adm. 2008;38(5):230-236. doi:10.1097/01.NNA.0000312770.19481.ce. https://psnet.ahrq.gov/issue/cost-nurse-sensitive-adverse-events This study determined that the actual direct cost of an adverse ev…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44567/psn-pdf
    October 14, 2015 - The misery of a doctor's first days. October 14, 2015 Hester JL. The Atlantic. October 1, 2015. https://psnet.ahrq.gov/issue/misery-doctors-first-days Although there is no consensus regarding whether the "July effect" actually exists, it is not hard to imagine the difficulties associated with the first days of pra…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46800/psn-pdf
    May 16, 2018 - Ireland investigates cervical cancer screening scandal. May 16, 2018 O'Loughlin E. New York Times. April 30, 2018. https://psnet.ahrq.gov/issue/ireland-investigates-cervical-cancer-screening-scandal Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misr…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39516/psn-pdf
    June 27, 2011 - Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units. June 27, 2011 De Giorgi I, Fonzo-Christe C, Cingria L, et al. Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units. Int…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43376/psn-pdf
    January 16, 2017 - Resilience and resilience engineering in health care. January 16, 2017 Fairbanks RJ, Wears RL, Woods DD, et al. Resilience and resilience engineering in health care. Jt Comm J Qual Patient Saf. 2014;40(8):376-383. https://psnet.ahrq.gov/issue/resilience-and-resilience-engineering-health-care Resilience is a charac…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60309/psn-pdf
    May 06, 2020 - COVID-19 leads to increased need for dialysis machines. May 6, 2020 Mosley T. Here & Now. Boston Public Radio. April 27, 2020. https://psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines Comorbidities can result in unexpected care complexities. This article discusses an emerging challenge for …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35193/psn-pdf
    July 10, 2008 - Diagnostic error in internal medicine. July 10, 2008 Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499. https://psnet.ahrq.gov/issue/diagnostic-error-internal-medicine This study identified 100 cases of diagnostic error in internal medicine and conducte…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44269/psn-pdf
    July 01, 2015 - Accidental overdoses involving fluorouracil infusions. July 1, 2015 ISMP Medication Safety Alert! Acute Care Edition. June 18, 2015;20:1:5. https://psnet.ahrq.gov/issue/accidental-overdoses-involving-fluorouracil-infusions Describing three accidental overdoses of the antineoplastic drug fluorouracil which involved …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42452/psn-pdf
    July 31, 2013 - Development and content validation of a surgical safety checklist for operating theatres that use robotic technology. July 31, 2013 Ahmed K, Khan N, Khan MS, et al. Development and content validation of a surgical safety checklist for operating theatres that use robotic technology. BJU Int. 2013;111(7):1161-74. do…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39296/psn-pdf
    January 22, 2017 - Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. January 22, 2017 Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86. https://psnet.ahrq.gov/issue/applying-lea…

  20. A hospital-randomized controlled trial of an educational quality improvement intervention in rural and small community hospitals in Texas following implementation of information technology. | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/rural-hospital-collaborative-excellence-using-it/citation/hospital
    January 01, 2023 - A hospital-randomized controlled trial of an educational quality improvement intervention in rural and small community hospitals in Texas following implementation of information technology. Citation Filardo G, Nicewander D, Hamilton C, et al. A hospital-randomized controlled trial of an educational qu…
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