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Showing results for "failures".

  1. Assess and Adapt: Understanding the Science of Safety and Reliability | Agency for Healthcare Research and Quality

    ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-slides.html
    July 01, 2018 - Slide 17 System Failures Leading to Error (Reason, 1990) Image: Four chunks of swiss cheese with

  2. Welcome Guide for New TeamSTEPPS Trainers | Agency for Healthcare Research and Quality

    ce.effectivehealthcare.ahrq.gov/teamstepps-program/welcome-guides/new-trainers.html
    July 01, 2023 - While reflecting on patient harms that resulted from systemic and teamwork failures can have value, consider

  3. Reducing Workplace Violence with TeamSTEPPS® | Agency for Healthcare Research and Quality

    ce.effectivehealthcare.ahrq.gov/teamstepps/events/webinars/dec-2016.html
    July 01, 2018 - Situation Awareness-oriented design and training creates Safety : Reduce human errors and system failures

  4. Previous TeamSTEPPS Webinars: 2016 | Agency for Healthcare Research and Quality

    ce.effectivehealthcare.ahrq.gov/teamstepps/webinars/previous-webinars-2016.html
    June 01, 2017 - Discuss some lessons learned through both successes and failures.

  5. Quality Improvement Strategies | Agency for Healthcare Research and Quality

    ce.effectivehealthcare.ahrq.gov/pqmp/implementation-qi/toolkit/child-hcahps/qi-strategies.html
    August 01, 2021 - Following the intervention, there were lower rates of discharge-related care failures, decreasing from

  6. Acute Care Behavior Change Theory for Antibiotic Stewardship Leaders

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-slides.pptx
    November 01, 2019 - Antibiotic Use – Acute Care Behavior Changes – Antibiotic Prescribing 17 Stewardship Team Communication Failures

  7. Preventing Pressure Injuries in Hospitals

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
    June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes

  8. Table of Contents: Volume 1. Assessment (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
    December 22, 2008 - Effects Analysis Based on in Situ Simulations: A Methodology to Improve Understanding of Risks and Failures

  9. Table of Contents: Volume 4. Technology and Medication Safety (pdf file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
    December 22, 2008 - Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures

  10. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. | PSNet

    psnet.ahrq.gov/issue/incidence-adverse-drug-reactions-hospitalized-patients-meta-analysis-prospective-studies
    October 04, 2017 - September 20, 2023 Decreasing handoff-related care failures in children's hospitals.

  11. Fall-related injuries in acute care: reducing the risk of harm. | PSNet

    psnet.ahrq.gov/issue/fall-related-injuries-acute-care-reducing-risk-harm
    March 28, 2018 - October 19, 2022 Operational failures detected by frontline acute care nurses.

  12. Measuring quality. | PSNet

    psnet.ahrq.gov/issue/measuring-quality
    June 21, 2017 - July 22, 2020 Frequency and nature of communication and handoff failures in medical malpractice

  13. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. | PSNet

    psnet.ahrq.gov/issue/incidence-adverse-events-swedish-hospitals-retrospective-medical-record-review-study
    August 05, 2009 - November 7, 2018 Failures in the respectful care of critically ill patients.

  14. Teamwork and total quality management: a durable partnership. | PSNet

    psnet.ahrq.gov/issue/teamwork-and-total-quality-management-durable-partnership
    September 11, 2019 - May 25, 2016 Routine failures in the process for blood testing and the communication

  15. "Free lessons" in aviation safety. | PSNet

    psnet.ahrq.gov/issue/free-lessons-aviation-safety
    October 19, 2022 - The postpartum hemorrhage patient safety bundle implementation at a single institution: successes, failures

  16. Medication administration errors and the pediatric population: a systematic search of the literature. | PSNet

    psnet.ahrq.gov/issue/medication-administration-errors-and-pediatric-population-systematic-search-literature
    September 16, 2015 - February 18, 2015 Decreasing handoff-related care failures in children's hospitals.

  17. Changes in the diagnostic process during 40 years of clinicopathologic conferences. | PSNet

    psnet.ahrq.gov/issue/changes-diagnostic-process-during-40-years-clinicopathologic-conferences
    March 20, 2024 - both by clinical topic and error type to better understand the trends and patterns seen in diagnostic failures

  18. Developing a culture of collaboration in the operating room: more than effective communication. | PSNet

    psnet.ahrq.gov/issue/developing-culture-collaboration-operating-room-more-effective-communication
    June 27, 2018 - September 22, 2021 Communication failures contributing to patient injury in anaesthesia

  19. Making the journey safe: recognising and responding to severe sepsis in accident and emergency. | PSNet

    psnet.ahrq.gov/issue/making-journey-safe-recognising-and-responding-severe-sepsis-accident-and-emergency
    April 27, 2022 - June 5, 2024 Operational failures in general practice: a consensus-building study on

  20. The impact of transitioning from a 24-hour to a 16-hour call model amongst a cohort of Canadian anesthesia residents at McMaster University—a survey study. | PSNet

    psnet.ahrq.gov/issue/impact-transitioning-24-hour-16-hour-call-model-amongst-cohort-canadian-anesthesia-residents
    June 03, 2020 - March 6, 2005 Decreasing handoff-related care failures in children's hospitals.
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