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psnet.ahrq.gov/issue/ssssh-handover-protected-medical-handover-optimising-quality-and-prioritising-safety-regional
March 08, 2017 - WebM&M Cases
Delay in Malignancy Diagnosis Reflects Systemic Failures
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psnet.ahrq.gov/issue/use-critical-incident-reports-medical-education-perspective
May 30, 2018 - Improving patient safety governance and systems through learning from successes and failures
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psnet.ahrq.gov/periodic-issue/weekly-resource-0
October 30, 2024 - This book discusses systemic failures caused by an overreliance on erroneous or out-of-date approaches
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psnet.ahrq.gov/periodic-issue/periodic-issue-455
September 25, 2024 - recognition software and highlights simulation, error reporting, and team involvement as avenues to minimize failures
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psnet.ahrq.gov/periodic-issue/periodic-issue-462
October 30, 2024 - As a result, medical schools now include curricula on identifying system failures and reporting them
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psnet.ahrq.gov/node/49610/psn-pdf
October 01, 2010 - operations but often under extenuating
circumstances, such as complicated patient factors (61%) or systems failures
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psnet.ahrq.gov/node/33693/psn-pdf
February 01, 2010 - Communication failures: an insidious contributor to medical
mishaps. Acad Med. 2004;79:186-194.
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psnet.ahrq.gov/node/33721/psn-pdf
November 01, 2011 - Providing routine maintenance and dealing with
unexpected equipment failures can be complex so we cannot
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - the transfer of patients between hospitals
Efficiency of the transfer
Technical problems (equipment failures
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psnet.ahrq.gov/node/33628/psn-pdf
February 01, 2006 - that they can report their errors so risk management can look into the organization's latent system
failures
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psnet.ahrq.gov/node/49472/psn-pdf
March 01, 2005 - Reporting
This case also involves a reportable disease, and therefore demonstrates one or more possible failures
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psnet.ahrq.gov/node/838972/psn-pdf
October 27, 2022 - anger about how they were treated by health care providers.3 While this case has some
obvious systems failures
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - Communication failures in patient sign-out
and suggestions for improvement: a critical incident analysis
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psnet.ahrq.gov/node/836978/psn-pdf
May 16, 2022 - Incidence of patient safety events and process-related human
failures during intra-hospital transportation
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psnet.ahrq.gov/web-mm/obstructed-view
August 07, 2019 - January 10, 2024
Patients' perspectives on quality and patient safety failures: lessons
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - violations.(3) The authors’ detailed
analysis pointed to “inadequate use of technology” and “design failures
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www.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
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psnet.ahrq.gov/node/33886/psn-pdf
August 01, 2019 - organizations may want to consider informally exchanging information about scribe program
successes and failures
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psnet.ahrq.gov/node/33650/psn-pdf
May 01, 2007 - A more open culture, in which errors or service failures can be reported and discussed.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - *
*
Errors with PN
As in this case, most PN errors are due to multiple failures in the process