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Showing results for "failures".

61. Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study. | PSNet
    psnet.ahrq.gov/issue/identification-and-characterization-failures-infectious-agent-transmission-precaution
    October 13, 2018 - Emerging Classic Identification and characterization of failures … Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices … This direct observation study observed frequent failures in use of PPE, including entering rooms without … The authors suggest that given the wide range of failures, a variety of strategies are needed to improve … Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices

62. 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

63. Using incident reports to assess communication failures and patient outcomes. | PSNet
    psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes
    February 06, 2019 - Study Using incident reports to assess communication failures and patient outcomes … Using Incident Reports to Assess Communication Failures and Patient Outcomes. … Communication failures are a common underlying factor in adverse events. … Although the relationship between communication failures and safety has been best studied in the operating … Using Incident Reports to Assess Communication Failures and Patient Outcomes.

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. Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. | PSNet
    psnet.ahrq.gov/issue/closing-loop-test-results-reduce-communication-failures-rapid-review-evidence-practice-and
    March 11, 2020 - Review Closing the loop on test results to reduce communication failures: a rapid … Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice … systematic and narrative reviews from multiple perspectives discussing diagnostic test result communication failures … Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice

66. 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.

67. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
    January 01, 2003 - Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities … 395 Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care … models provide contextual maps of the errors and behaviors that lead to medication delivery system failures … Risk modeling teams then identify the failures that link together, leading to the top-level event. … The models provide contextual maps of the errors and behaviors that lead to system failures so that

68. Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events. | PSNet
    psnet.ahrq.gov/issue/health-literacy-related-safety-events-qualitative-study-health-literacy-failures-patient
    August 24, 2022 - Study Health literacy-related safety events: a qualitative study of health literacy failures … Health literacy-related safety events: a qualitative study of health literacy failures in patient safety … e.g., unclear discharge medication instructions, conflicting instructions), system processes (e.g.., failures … Health literacy-related safety events: a qualitative study of health literacy failures in patient safety

69. Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department. | PSNet
    psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital
    June 22, 2017 - Study Using failure mode and effect analysis to identify potential failures in a … Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … this study, FMEA was used in a psychiatric hospital emergency department (ED) to identify potential failures … Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency

70. 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

71. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. | PSNet
    psnet.ahrq.gov/issue/evaluation-preoperative-checklist-and-team-briefing-among-surgeons-nurses-and
    August 28, 2013 - a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures … a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures … Structured communication tools are being used increasingly to prevent critical communication failures … a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures … August 28, 2013 Using trainee failures to enhance learning: a qualitative study of pediatric

72. 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

73. 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

74. 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

75. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. | PSNet
    psnet.ahrq.gov/issue/impact-extended-duration-shifts-medical-errors-adverse-events-and-attentional-failures
    February 02, 2011 - Impact of extended-duration shifts on medical errors, adverse events, and attentional failures … Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. … extended shifts were much more likely to report both significant preventable errors and attentional failures … Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. … January 10, 2017 Effect of reducing interns' weekly work hours on sleep and attentional failures

76. Surgical technology and operating-room safety failures: a systematic review of quantitative studies. | PSNet
    psnet.ahrq.gov/issue/surgical-technology-and-operating-room-safety-failures-systematic-review-quantitative-studies
    May 06, 2015 - Review Surgical technology and operating-room safety failures: a systematic review … Surgical technology and operating-room safety failures: a systematic review of quantitative studies. … Surgical equipment failures have been implicated as a significant contributor to errors and delays … Surgical technology and operating-room safety failures: a systematic review of quantitative studies. … October 19, 2022 An observational study of the frequency, severity, and etiology of failures

77. 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

78. 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

79. 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

80. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/baker.html
    August 01, 2017 - Type of event seemed to affect what failures clinicians indicated should be disclosed, while type of … event had little effect on what failures patients and family members indicated should be disclosed. … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … We then examined the failures across events to create a common set of failures by the phases of the L … to the clinician rankings of the same failures.