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Showing results for "failures".

81. 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

82. 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

83. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. | PSNet
    psnet.ahrq.gov/issue/communication-failures-patient-sign-out-and-suggestions-improvement-critical-incident
    April 16, 2008 - Study Communication failures in patient sign-out and suggestions for improvement: … Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis … The authors interviewed interns to understand communication failures with patient transfer processes. … Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis

84. 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.

85. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/865807/psn-pdf
    May 08, 2024 - Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into … Patients’ perspectives on quality and patient safety failures: lessons learned from an inquiry into … https://psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned … https://psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry … https://psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry

86. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/60234/psn-pdf
    April 15, 2020 - Mistakes, Errors and Failures across Cultures. April 15, 2020 Vanderheiden E, Mayer C, eds. … ISBN 9783030355739 https://psnet.ahrq.gov/issue/mistakes-errors-and-failures-across-cultures-navigating-potentials … https://psnet.ahrq.gov/issue/mistakes-errors-and-failures-across-cultures-navigating-potentials https … https://psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern … https://psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern

87. Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA. | PSNet
    psnet.ahrq.gov/issue/pathology-oversight-failures-veterans-health-care-system-ozarks-fayetteville-arkansas-va
    July 14, 2021 - Book/Report Pathology Oversight Failures at the Veterans Health Care System of the … Citation Text: Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville … URL Cite Citation Citation Text: Pathology Oversight Failures … July 26, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with … February 10, 2021 Failures in Care Coordination and Reviewing a Patient's Death at the

88. Failure to debrief after critical events in anesthesia is associated with failures in communication during the event. | PSNet
    psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures-communication-during
    September 24, 2018 - Emerging Classic Failure to debrief after critical events in anesthesia is associated with failures … Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during … Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures … Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during

89. Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation. | PSNet
    psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-proactive-identification-communication-and-handoff
    August 04, 2021 - Use of failure mode and effects analysis for proactive identification of communication and handoff failures … Use of failure mode and effects analysis for proactive identification of communication and handoff failures … Use of failure mode and effects analysis for proactive identification of communication and handoff failures … December 21, 2014 Deconstructing intraoperative communication failures.

90. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/74722/psn-pdf
    February 02, 2022 - Preventing and mitigating radiology system failures: a guide to disaster planning. … Preventing and mitigating radiology system failures: a guide to disaster planning. … https://psnet.ahrq.gov/issue/preventing-and-mitigating-radiology-system-failures-guide-disaster-planning … hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures … https://psnet.ahrq.gov/issue/preventing-and-mitigating-radiology-system-failures-guide-disaster-planning

91. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837866/psn-pdf
    August 17, 2022 - A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and … https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ- procurement-and … Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed. … https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-procurement-and … https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-procurement-and

92. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36021/psn-pdf
    September 24, 2016 - Operational failures and interruptions in hospital nursing. … Operational failures and interruptions in hospital nursing. … https://psnet.ahrq.gov/issue/operational-failures-and-interruptions-hospital-nursing This study discovered … that nurses experienced more than eight work system failures during an 8-hour shift. … The most frequent failures identified involved medications, orders, supplies, staffing, and equipment

93. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/857452/psn-pdf
    December 06, 2023 - Improving patient safety governance and systems through learning from successes and failures: qualitative … Improving patient safety governance and systems through learning from successes and failures: qualitative … psnet.ahrq.gov/issue/improving-patient-safety-governance-and-systems-through-learning- successes-and-failures … psnet.ahrq.gov/issue/improving-patient-safety-governance-and-systems-through-learning-successes-and-failures … psnet.ahrq.gov/issue/improving-patient-safety-governance-and-systems-through-learning-successes-and-failures

94. Fault Tree Analysis | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fault-tree-analysis
    January 01, 2023 - Acronym FTA Description Fault tree analyses (FTAs) study specific system, process, or product failures … ANALYZE THE TREE to understand how the causes are interrelated and think of how to prevent failures. … Pay closest attention to failures that are the most likely to happen. … Useful for modeling team-based failures.

95. "What's psychology got to do with it?" Applying psychological theory to understanding failures in modern healthcare settings. | PSNet
    psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern
    July 10, 2017 - Applying psychological theory to understanding failures in modern healthcare settings. … Applying psychological theory to understanding failures in modern healthcare settings. … from psychology , including theories related to behavior and cognition , to understand why care failures … Applying psychological theory to understanding failures in modern healthcare settings.

96. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837677/psn-pdf
    July 13, 2022 - Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton … https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer- … hampton-va-medical Cancer test communication failures can contribute to physical, emotional, and financial … https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical … https://psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical

97. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/844047/psn-pdf
    February 08, 2023 - Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing … Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing … https://psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists … 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

98. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/46036/psn-pdf
    July 05, 2017 - Operational failures detected by frontline acute care nurses. … Operational Failures Detected by Frontline Acute Care Nurses. … https://psnet.ahrq.gov/issue/operational-failures-detected-frontline-acute-care-nurses This prospective … reporting study asked frontline nurse participants to record operational failures, or breakdowns in … Nurses recorded about six such failures per shift, suggesting that systems failures are common in acute

99. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

100. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - These result in latent failures. … These result in active failures. … Slide 3 System Failures SAY: System failures are considered latent problems. … Slide 4 Active Failures SAY: Active failures occur because of human error. … Does the problem you are addressing involve latent failures, active failures, or both?