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Showing results for "failures".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49529/psn-pdf
    February 01, 2007 - and directed to a dedicated anticoagulation pharmacist, and it works well.(11) Overall, multiple failures

  2. Chapter 2. Building the Project Foundation: Project Teams and Scope | Agency for Healthcare Research and Quality

    www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-2.html
    July 01, 2022 - Potential failures. Unnecessary redundancies and gaps in the process.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72587/psn-pdf
    December 23, 2020 - A systematic review of failures in handoff communication during intrahospital transfers. 

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49583/psn-pdf
    April 01, 2009 - Failures in communication and ineffective teamwork are leading causes of patient harm.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49769/psn-pdf
    September 01, 2016 - The aim should be a just culture where physicians are not punished for isolated lapses or systems failures

  6. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
    July 01, 2023 - Slide 22: The Second Victim: Health Care Workers Say: Adverse events are often system failures.

  7. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. | PSNet

    psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
    October 27, 2021 - anesthesia-related sentinel events from 2004-2014 found that 57 were attributable to communication failures

  8. Surprise Wire | PSNet

    psnet.ahrq.gov/web-mm/surprise-wire
    July 15, 2020 - Commission on Accreditation of Healthcare Organizations (JCAHO) revealed that 65% derive from communication failures

  9. When "Psychiatric" Symptoms Are Not | PSNet

    psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
    September 20, 2011 - Table Related Resources From the Same Author(s) Contextual errors and failures

  10. Approach to Improving Patient Safety: Communication | PSNet

    psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
    August 31, 2020 - burden of gathering key diagnostic information, technical problems, data entry problems, and system failures

  11. The Physical Environment: An Often Unconsidered Patient Safety Tool | PSNet

    psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
    November 21, 2018 - the Figure , environmental latent conditions undermine system defenses, setting the stage for active failures

  12. It's All in the Syringe | PSNet

    psnet.ahrq.gov/web-mm/its-all-syringe
    February 01, 2013 - January 6, 2017 Process of care failures in breast cancer diagnosis.

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

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
    January 01, 2025 - Effects Analysis Based on in Situ Simulations: A Methodology to Improve Understanding of Risks and Failures

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

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
    January 01, 2025 - Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures

  15. Patient Safety 101 | PSNet

    psnet.ahrq.gov/primer/patient-safety-101
    January 16, 2025 - analyzed errors in fields as diverse as aviation and nuclear power—revealed that catastrophic safety failures

  16. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
    February 01, 2025 - Excellence In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures

  17. Inpatient Transitions of Care: Challenges and Safety Practices | PSNet

    psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
    June 15, 2024 - December 27, 2014 A systematic review of failures in handoff communication during intrahospital transfers

  18. An Untimely End Despite End-of-Life Care Planning | PSNet

    psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
    February 01, 2012 - October 23, 2024 Trainees' perceptions of patient safety practices: recounting failures

  19. Preventing Pressure Injuries in Hospitals

    www.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

  20. Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides1.html
    October 01, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
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