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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33721/psn-pdf
    November 01, 2011 - Providing routine maintenance and dealing with unexpected equipment failures can be complex so we cannot

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33650/psn-pdf
    May 01, 2007 - A more open culture, in which errors or service failures can be reported and discussed.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33628/psn-pdf
    February 01, 2006 - that they can report their errors so risk management can look into the organization's latent system failures

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49472/psn-pdf
    March 01, 2005 - Reporting This case also involves a reportable disease, and therefore demonstrates one or more possible failures

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72587/psn-pdf
    December 23, 2020 - A systematic review of failures in handoff communication during intrahospital transfers. 

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33886/psn-pdf
    August 01, 2019 - organizations may want to consider informally exchanging information about scribe program successes and failures

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49490/psn-pdf
    September 01, 2005 - violations.(3) The authors’ detailed analysis pointed to “inadequate use of technology” and “design failures

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49610/psn-pdf
    October 01, 2010 - operations but often under extenuating circumstances, such as complicated patient factors (61%) or systems failures

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33693/psn-pdf
    February 01, 2010 - Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186-194.

  10. Strategies for Improving Patient Experience with Ambulatory Care: Reminder Systems for Immunizations and Preventive Services (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/health-promotion-education/cahps-strategy-6-r.pdf
    April 14, 2017 - Does the reminder system meet physicians’ needs while also incorporating safeguards against process failures

  11. Pf-Engagement-Facilitator-Guide (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
    May 01, 2017 - Slide 21 SAY: Adverse events are often system failures.

  12. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
    July 01, 2023 - Slide 22: The Second Victim: Health Care Workers Say: Adverse events are often system failures.

  13. Chapter 2. Building the Project Foundation: Project Teams and Scope | Agency for Healthcare Research and Quality

    www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-2.html
    July 01, 2022 - Potential failures. Unnecessary redundancies and gaps in the process.

  14. Acute Care Behavior Change Theory for Antibiotic Stewardship Leaders

    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-slides.pptx
    November 01, 2019 - Antibiotic Use – Acute Care Behavior Changes – Antibiotic Prescribing 17 Stewardship Team Communication Failures

  15. Inpatient Transitions of Care: Challenges and Safety Practices | PSNet

    psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
    June 15, 2024 - December 27, 2014 A systematic review of failures in handoff communication during intrahospital transfers

  16. Avoiding Common Pitfalls | The Academy

    integrationacademy.ahrq.gov/products/playbooks/moud-playbook/avoiding-common-pitfalls
    August 01, 2025 - Don't treat continued substance use or missed appointments as treatment failures or reasons to "fire"

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33709/psn-pdf
    July 01, 2011 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

  18. The Physical Environment: An Often Unconsidered Patient Safety Tool | PSNet

    psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
    November 21, 2018 - the Figure , environmental latent conditions undermine system defenses, setting the stage for active failures

  19. An Untimely End Despite End-of-Life Care Planning | PSNet

    psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
    February 01, 2012 - October 23, 2024 Trainees' perceptions of patient safety practices: recounting failures

  20. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
    April 01, 2013 - * * Errors with PN As in this case, most PN errors are due to multiple failures in the process
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