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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
June 29, 2016 - Derangement
0.9 1.5 4 $120,629 $ 482,516 N 3 3 2 Y Y Y Y Y
PSI 11 Postoperative
Respiratory Failure … Y
IQI 15 AMI Mortality
6.5 5.0 16 $38,000 $ 608,000 N 3 2 2 Y Y Y Y Y
IQI 16 Heart Failure … 0.0 4.9 0 $75,932 $ - N 6 6 6 Y Y Y Y Y
PDI 09
Postoperative
Respiratory Failure
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cahps.ahrq.gov/whatsnew.html
April 01, 2024 - Prevention in Adults of Transmission of Infection With Multidrug-Resistant Organisms (4/15/24)
Failure
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cahps.ahrq.gov/news/newsletters/e-newsletter/871.html
July 01, 2023 - of COVID-19
A new Data Spotlight (PDF, 1 MB) from AHRQ shows that hospital admissions for heart failure … decreased by 15 percent from 2019 to 2020, while deaths from heart failure more than doubled.
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/lepevidencesum.pdf
January 01, 2012 - $5 million over a 4-year
period.
5
Almost all of these claims related to poor communication and failure
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cahps.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/health-promotion-education/strategy6r-reminder-systems.html
March 01, 2020 - Failure to consider these questions is likely to undermine the success of the reminder system. … Failure to keep clinic appointments: Implications for residency education and productivity.
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cahps.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - Iatrogenic Pneumothorax (PSI 6)
PSI
Post-Op Hemorrhage or Hematoma (PSI 9)
PSI
Post-Op Respiratory Failure … sample, and those with a principal diagnosis of acute myocardial infarction (AMI), congestive heart failure … Post-Op Hemorrhage or Hematoma (PSI 9)
20,691
32,750,000
0.632
PSI
Post-Op Respiratory Failure
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cahps.ahrq.gov/sites/default/files/wysiwyg/news/events/conference/2011/naylor/naylor.pptx
January 01, 2011 - Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. … Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial.
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cahps.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/strategy6c-opennotes.html
March 01, 2020 - For example, a patient whose chart includes an unfamiliar reference to "congestive heart failure" might … think it refers to an actual failure rather than a manageable heart condition.
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - three individual factors identified were chronic medical conditions, substance abuse, and
delay and/or failure … identified were chronic medical conditions, substance abuse, and
A-25 | P a g e
delay and/or failure … These 18 events included those occurring during surgeries and other
procedures (e.g., failure of sterility … wrong body part); pregnancy, labor and
delivery, and newborn care (e.g., nondetection of Rh factor, failure
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cahps.ahrq.gov/news/newsletters/e-newsletter/882.html
September 01, 2023 - Among 20 indicators of severe maternal morbidity, acute kidney failure had the greatest increase, from … Literature
Postdischarge noninvasive telemonitoring and nurse telephone coaching improve outcomes in heart failure
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cahps.ahrq.gov/teamstepps/instructor/essentials/implguide2.html
November 01, 2018 - Study the flowchart and then:
Mark potential failure points in the redesigned processes. … Incorporates redundancy and back-up systems to minimize risk of patient harm in event of error or process failure
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cahps.ahrq.gov/news/newsroom/ahrq-stats.html
November 01, 2023 - Among 20 indicators of severe maternal morbidity, acute kidney failure had the greatest increase, from … Increased Hospital Stays for Kidney Failure
While the overall rate of hospital stays for acute kidney … failure increased 66 percent nationwide between 2005 and 2014, the increase was higher for low-income … Cost of Hospital Stays for Kidney Failure
The cost for a hospital stay in 2014 involving acute kidney … failure averaged $19,200, nearly twice the $9,900 average cost for stays not involving kidney failure
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cahps.ahrq.gov/talkingquality/assess/why-evaluate.html
May 01, 2019 - All participants in a report card project will reach conclusions about the relative success or failure
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cahps.ahrq.gov/news/newsletters/e-newsletter/877.html
August 01, 2023 - Evaluating the implementation of patient-reported outcomes in heart failure clinic: a qualitative assessment
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cahps.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar04/formativeevalsl.html
January 01, 2014 - Barriers and facilitators to implementation success or failure. … Can provide working hypotheses on implementation success / failure.
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cahps.ahrq.gov/patient-safety/settings/hospital/resource/qitool/index.html
March 01, 2017 - Hemorrhage PDF [76.1 KB] PSI10 Postoperative Derangement PDF [86 KB] PSI11 Postoperative Respiratory Failure … Surgery PDF [74.18 KB] PDI08 Perioperative Hemorrhage PDF [81 KB] PDI09 Postoperative Respiratory Failure
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cahps.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
July 14, 2023 - related to financial payouts; up to one-
third of all cases that end in a claim have a diagnostic failure
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
June 01, 2014 - PSI Post-Op Hemorrhage
or Hematoma (PSI 9)
21,000 0.63 20,000 0.60
PSI Post-Op Respiratory
Failure
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cahps.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
October 01, 2023 - Skip to main content
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/implguide_0.pdf
March 01, 2006 - variety of sources, including
adverse event and near-miss reports, reports of root cause analyses or failure … Reviewing reports of root cause analyses and failure modes and effects analyses. … process as you imagine it would look with your TeamSTEPPS
Intervention in place.
Identify potential failure … Failure to show improvement in team performance or in clinical outcomes may be due
to the staff’s failure … Mark potential failure points in the redesigned processes.