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Showing results for "failures".

61. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. | PSNet
    psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
    November 16, 2022 - The model discussed focuses on two types of failures, which share equal importance in analysis but distinguish … The first, active failures , consists of mistakes made by providers in the delivery of care. … The second, latent failures , represents flaws in the systems of care. … The authors use a case example in anesthesia to illustrate how searching for active failures alone fails … analysis of past disasters has offered a useful model to differentiate provider from organizational failures

62. Preventing and mitigating radiology system failures: a guide to disaster planning. | PSNet
    psnet.ahrq.gov/issue/preventing-and-mitigating-radiology-system-failures-guide-disaster-planning
    November 23, 2016 - Commentary Preventing and mitigating radiology system failures: a guide to disaster … Preventing and mitigating radiology system failures: a guide to disaster planning. … hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures … Preventing and mitigating radiology system failures: a guide to disaster planning. … February 9, 2011 Profiles in patient safety: misplaced femoral line guidewire and multiple failures

63. Effect of reducing interns' weekly work hours on sleep and attentional failures. | PSNet
    psnet.ahrq.gov/issue/effect-reducing-interns-weekly-work-hours-sleep-and-attentional-failures
    January 10, 2017 - Study Effect of reducing interns' weekly work hours on sleep and attentional failures … Effect of reducing interns' weekly work hours on sleep and attentional failures. … that limiting intern work hours to less than 80 hours per week led to more sleep and less attentional failures … least one electrooculophaphy-derived slow eye movement while at work, a validated marker for attention failures … Effect of reducing interns' weekly work hours on sleep and attentional failures.

64. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72537/psn-pdf
    December 02, 2020 - Automation failures and patient safety. December 2, 2020 Ruskin KJ, Ruskin AC, O’Connor M. … Automation failures and patient safety. … https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety Task automation in medicine is a … This review examines automation failures in anesthesiology. … https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety https://psnet.ahrq.gov/issue/role-automation-complex-system-failures

65. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46922/psn-pdf
    January 01, 2019 - Reducing interdisciplinary communication failures through secure text messaging: a quality improvement … Reducing Interdisciplinary Communication Failures Through Secure Text Messaging. … https://psnet.ahrq.gov/issue/reducing-interdisciplinary-communication-failures-through-secure-text- … messaging-quality Communication failures are a key contributor to preventable adverse events. … https://psnet.ahrq.gov/issue/reducing-interdisciplinary-communication-failures-through-secure-text-messaging-quality

66. Improving patient safety by identifying latent failures in successful operations. | PSNet
    psnet.ahrq.gov/issue/improving-patient-safety-identifying-latent-failures-successful-operations
    September 15, 2010 - Study Improving patient safety by identifying latent failures in successful operations … Improving patient safety by identifying latent failures in successful operations. … Improving patient safety by identifying latent failures in successful operations.

67. TeamSTEPPS® Diagnosis Improvement: Infographic (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/dxsafety-infographic.pdf
    February 01, 2022 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … patients experiences a diagnostic error firsthand.11 in 3 Diagnostic-related communication failures … 2012.pdf https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

68. TeamSTEPPS® Diagnosis Improvement: Infographic (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-infographic.pdf
    February 01, 2022 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … patients experiences a diagnostic error firsthand.11 in 3 Diagnostic-related communication failures … 2012.pdf https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

69. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/851651/psn-pdf
    July 26, 2023 - Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … https://psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric … this study, FMEA was used in a psychiatric hospital emergency department (ED) to identify potential failures … https://psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital

70. Reducing interdisciplinary communication failures through secure text messaging: a quality improvement project. | PSNet
    psnet.ahrq.gov/issue/reducing-interdisciplinary-communication-failures-through-secure-text-messaging-quality
    May 08, 2017 - Study Reducing interdisciplinary communication failures through secure text messaging … Reducing Interdisciplinary Communication Failures Through Secure Text Messaging. … Communication failures are a key contributor to preventable adverse events . … Reducing Interdisciplinary Communication Failures Through Secure Text Messaging.

71. Using incident reports to assess communication failures and patient outcomes. | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/effect-health-information-technology-health-care-provider-communication/citation/using
    January 01, 2023 - Using incident reports to assess communication failures and patient outcomes. … Using Incident Reports to Assess Communication Failures and Patient Outcomes.

72. 130-Ss-Swiss-Cheese-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
    April 01, 2025 - To ensure a defect never happens again, failures should be viewed from a systems lens to improve the … the “Swiss cheese model” to illustrate how system failures occur and why some failures lead to an event … Active failures occur when an “operator” performs an unsafe action that leads to an event. … active failures. … In other words, active failures are the adverse events the team thinks about and attempts to avoid.

73. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866195/psn-pdf
    June 26, 2024 - This article describes seven studies concerning people’s estimates of learning from previous failures … https://psnet.ahrq.gov/issue/strategies-learning-failure https://psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists-allowing … https://psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists-allowing … https://psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons

74. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/864377/psn-pdf
    March 13, 2024 - Patients' experiences of dental diagnostic failures: a qualitative study using social media. … Patients' experiences of dental diagnostic failures: a qualitative study using social media. … https://psnet.ahrq.gov/issue/patients-experiences-dental-diagnostic-failures-qualitative-study-using-social … https://psnet.ahrq.gov/issue/patients-experiences-dental-diagnostic-failures-qualitative-study-using-social-media … https://psnet.ahrq.gov/issue/patients-experiences-dental-diagnostic-failures-qualitative-study-using-social-media

75. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73537/psn-pdf
    July 28, 2021 - Health literacy-related safety events: a qualitative study of health literacy failures in patient safety … Health literacy-related safety events: a qualitative study of health literacy failures in patient safety … https://psnet.ahrq.gov/issue/health-literacy-related-safety-events-qualitative-study-health-literacy-failures … e.g., unclear discharge medication instructions, conflicting instructions), system processes (e.g.., failures … https://psnet.ahrq.gov/issue/health-literacy-related-safety-events-qualitative-study-health-literacy-failures-patient

76. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/72509/psn-pdf
    November 25, 2020 - Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice … Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice … https://psnet.ahrq.gov/issue/closing-loop-test-results-reduce-communication-failures-rapid-review-evidence … systematic and narrative reviews from multiple perspectives discussing diagnostic test result communication failures … https://psnet.ahrq.gov/issue/closing-loop-test-results-reduce-communication-failures-rapid-review-evidence-practice-and

77. Preventing adverse events caused by emergency electrical power system failures. | PSNet
    psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures
    July 31, 2023 - Event Alerts Preventing adverse events caused by emergency electrical power system failures … Citation Text: Preventing adverse events caused by emergency electrical power system failures. … Citation Citation Text: Preventing adverse events caused by emergency electrical power system failures

78. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/73066/psn-pdf
    March 24, 2021 - Patient harm resulting from medication reconciliation process failures: a study of serious events reported … Patient harm resulting from medication reconciliation process failures: a study of serious events reported … https://psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study- … The most common process failures contributing to patient harm occurred during order entry/transcription … https://psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events

79. Clinical Investigation Booking Systems Failures: Written Communications in Community Languages. | PSNet
    psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-community-languages
    May 17, 2023 - Book/Report Clinical Investigation Booking Systems Failures: Written Communications … Citation Text: Clinical Investigation Booking Systems Failures: Written Communications in Community … Cite Citation Citation Text: Clinical Investigation Booking Systems Failures

80. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47502/psn-pdf
    June 02, 2019 - Failure to debrief after critical events in anesthesia is associated with failures in communication … Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication … https://psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures- communication-during … Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures … https://psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures-communication-during