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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-older-adults.pdf
January 17, 2024 - State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults
PATIENT
SAFETY
e
Issue Brief 22
State of the Science and Future
Directions To Improve Diagnostic
Safety in Older Adults
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e
Issue Brief 22
State of the Science and Future
Directions…
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www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/exe-summary.html
March 01, 2020 - healthcare settings, especially transfer of patients from one setting to another
Communication failures
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/prehospital-airway-management-protocol.pdf
December 20, 2019 - Concern was expressed about the ability of the literature to reflect and report on unrecognized
failures
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psnet.ahrq.gov/perspective/safety-and-medical-education
December 01, 2013 - UME level, the Association of American Medical Colleges has defined the ability to "identify system failures
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - January 5, 2017
Preventing adverse events caused by emergency electrical power system failures
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - However, it will surely take time and patience, as these changes will bring as many failures as successes
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www.ahrq.gov/sites/default/files/2025-03/singh2-report.pdf
January 01, 2025 - failings and cognitive failings.(2) Among the most common
cognitive origins of diagnostic errors are failures
-
www.ahrq.gov/sites/default/files/2024-01/kharrazi-report.pdf
January 01, 2024 - These transition failures are
exacerbated by various disconnects between in- and outpatient settings
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www.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
January 01, 2010 - information for
2009
2010
and
beyond
11
understanding patient safety events
and health care system failures
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
January 01, 2014 - analysis and planning to prevent recurrences
Holds bills
In Malizzo case, critical to understanding system failures
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-appcusp.pdf
December 01, 2017 - Science of Safety Video
(Watch the video)
This video will help your teams to—
• Identify system failures
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - more and more to consumer-mediated exchange as a way to get past those disincentives, those market failures
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www.ahrq.gov/research/findings/final-reports/stpra/stpraapa2.html
April 01, 2018 - Equipment failures led to 17% of complications.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/sops-action-planning-tool.pdf
November 01, 2022 - Analysis of past failures can help you avoid making
similar mistakes in implementing your initiative
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - like there is something still inside me. "
The second case illustrates the consequences of process failures
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www.ahrq.gov/sites/default/files/2025-03/mahajan-manojlovich-report.pdf
January 01, 2025 - recent systematic review
revealed no existing framework or intervention for investigating communication failures
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-11-root-cause-analysis.pdf
December 27, 2021 - Physical causes
include failures of materials such as broken or
missing equipment.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Best_Practices_Hosp_Leaders_508.pdf
March 13, 2013 - This means telling patients’ stories, not just sharing statistics,
when discussing successes and failures
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www.ahrq.gov/patient-safety/reports/advancing/index.html
July 01, 2022 - be an important source of information for understanding patient safety events and health care system failures
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-medication-chartbook-2024.pdf
January 01, 2024 - events were divided into the following four description groups:
Incorrect action including process failures