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Showing results for "failures".

  1. Final Progress Report: Factors That Enhance Diagnostic Imaging Safety in the Ambulatory Setting (pdf file)

    www.ahrq.gov/sites/default/files/2025-03/lacson-report.pdf
    January 01, 2025 - Abstract Purpose: Assess the incidence of and types and contributing factors related to diagnostic failures … An additional “deep dive” on the incidence of and types and causes of factors related to failures related … Initiative for Patient Safety 2.0 framework (SEIPS 2.0) to identify contributing factors to diagnostic failures

  2. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
    January 01, 2022 - Spotlight Spotlight Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis Source and Credits • This presentation is based on the November 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Narath Carlile MD MPH,…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837658/psn-pdf
    July 08, 2022 - Preventable Transfer to the Hospital July 8, 2022 Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/preventable-transfer-hospital The Case A 78-year-old veteran with dementia-associated aggressive behavior and multiple comorbidities had…

  4. Most Common Diagnoses and Procedures in U.S. Community Hospitals, 1996

    hcup-us.ahrq.gov/reports/natstats/commdx/table1h.htm
    February 11, 2011 - Most Common Diagnoses and Procedures in U.S. Community Hospitals, 1996 Table 1 (continued). The top 100 principal procedures and their associated principal diagnoses: HCUP Nationwide Inpatient Sample, 1996 -------------------------------------------------------------------------------------------------------…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49691/psn-pdf
    September 01, 2013 - DRESSed for Failure September 1, 2013 Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dressed-failure The Case A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand cellulitis and an uncomplicated urinary tract infec…

  7. An Easily Forgotten Tube | PSNet

    psnet.ahrq.gov/web-mm/easily-forgotten-tube
    June 01, 2016 - An Easily Forgotten Tube Citation Text: Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

  8. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
    January 01, 2003 - When errors occur, they are likely to be viewed as failures of character (i.e., the error occurred

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49651/psn-pdf
    May 01, 2012 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

  10. An Obstructed View | PSNet

    psnet.ahrq.gov/web-mm/obstructed-view
    August 07, 2019 - January 10, 2024 Patients' perspectives on quality and patient safety failures: lessons

  11. When "Psychiatric" Symptoms Are Not | PSNet

    psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
    September 20, 2011 - Table Related Resources From the Same Author(s) Contextual errors and failures

  12. Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides1.html
    October 01, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes

  13. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. | PSNet

    psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
    October 27, 2021 - anesthesia-related sentinel events from 2004-2014 found that 57 were attributable to communication failures

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49583/psn-pdf
    April 01, 2009 - Failures in communication and ineffective teamwork are leading causes of patient harm.

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838972/psn-pdf
    October 27, 2022 - anger about how they were treated by health care providers.3 While this case has some obvious systems failures

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836978/psn-pdf
    May 16, 2022 - Incidence of patient safety events and process-related human failures during intra-hospital transportation

  17. Surprise Wire | PSNet

    psnet.ahrq.gov/web-mm/surprise-wire
    July 15, 2020 - Commission on Accreditation of Healthcare Organizations (JCAHO) revealed that 65% derive from communication failures

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49769/psn-pdf
    September 01, 2016 - The aim should be a just culture where physicians are not punished for isolated lapses or systems failures

  19. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
    February 01, 2025 - Excellence In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49529/psn-pdf
    February 01, 2007 - and directed to a dedicated anticoagulation pharmacist, and it works well.(11) Overall, multiple failures
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