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Showing results for "failures".

81. 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

82. 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.

83. 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

84. 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

85. 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

86. 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

87. 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

88. 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

89. 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

90. 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

91. 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

92. 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

93. 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

94. 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

95. 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

96. 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

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/41228/psn-pdf
    August 02, 2012 - Identifying the latent failures underpinning medication administration errors: an exploratory study. … Identifying the latent failures underpinning medication administration errors: an exploratory study. … https://psnet.ahrq.gov/issue/identifying-latent-failures-underpinning-medication-administration-errors … - exploratory-study This study identified 10 latent failures that contributed to medication administration … Ward climate, the most prevalent theme, was noted to interact with other failures such as workload,

99. 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/resources/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.

100. 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.