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Showing results for "failure".

41. Long COVID is a Case Study of Our Fractured Healthcare System | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/news/blog/ahrqviews/long-covid.html
    March 01, 2023 - Each represented a failure of our healthcare system to handle a new and growing challenge that requires … But our failure to address Long COVID has revealed severe, life-threatening gaps in care.

42. Strategies for Improving Patient Experience with Ambulatory Care: Service Recovery Programs (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-p.pdf
    November 02, 2017 - dissatisfied or lost members or patients by identifying and fixing the problem or making amends for the failure … Letting the person tell their story and describe the impact of the failure is essential. … Commit to identifying failure points in the system • Using complaint data, identify failure points

43. Specific Tools To Support Change (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/g2_combo_specifictoolstosupportchange.pdf
    January 01, 2011 - 20download/St akeholder%20analysis.do c Institute for Healthcare Improvement Analysis Tool Failure … Modes and Effects Analysis Tool Failure Modes and Effects Analysis (FMEA) is a systematic, proactive … FMEA includes review of the following: • Steps in the process • Failure modes (What could go wrong … • Failure causes (Why would the failure happen?) … • Failure effects (What would be the consequences of each failure?)

44. Data Infographics | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/data/infographics/index.html
    March 01, 2024 - 2020 Adult Opioid Fills by Race Expenditures for COVID-19 Care in 2020 Heart Failure … Disease Declining Hospital Costs for Seniors with Traditional Medicare 2020 Heart Failure

45. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
    April 01, 2021 - USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities Introduction This user guide provides step-by-step instructions for nursing home staff to use the Hand Hygien…

46. Introduction to the Quality Indicators Best Practices Tool (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
    June 05, 2016 - PSI 10 Postoperative Physiologic and Metabolic Derangement Rate • PSI 11 Postoperative Respiratory Failure … Mortality Rate • PDI 08 Perioperative Hemorrhage or Hematoma Rate • PDI 09 Postoperative Respiratory Failure

47. NPSD Dashboards | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/npsd/data/dashboard/index.html
    October 01, 2023 - Dashboard Details the type of device; type of device by residual harm to the patient; device defect, failure … , or user error; device defect, failure, or user error by residual harm to the patient; type of health

48. Leveraging Cultural Change to Reduce Urinary Catheter Use | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/hai/cauti-tools/archived-webinars/leveraging-cultural-change-slides.html
    December 01, 2017 - experience, history and tradition Slide 7 The Culture of Safety and Assessment of Harm Believe that failure … to follow guidelines may cause harm Built in alerts Consequences for failure to implement Slide … feeding žPressors with minimal titration žChronic Lasix žMildly sedated or drowsy Respiratory failure

49. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/teamstepps/instructor/scenarios/ambulatory.html
    October 01, 2014 - Scenario 7 Scenario 8 Scenario 1 Appropriate for: All Specialties Setting: Clinic A renal failure … Failure to share information has a detrimental effect on patient care and may result in delayed diagnosis … This failure to communicate as soon as possible may have contributed to his demise.

50. TeamSTEPPS® 2.0 Leadership Briefing | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/teamstepps/about-teamstepps/leadershipbriefing.html
    April 01, 2017 - the sentinel events that were reported to them over the last 10 years and identified communication failure … reviewing a variety of sources, including adverse event and near-miss reports, root cause analyses or failure … Top of Page Slide 19: Importance of Communication Communication failure has been identified as … Communication failure is a primary contributing factor in almost 80% of more than 6,000 root cause analyses … the sentinel events that were reported to them over the last 10 years and identified communication failure

51. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/teamstepps/instructor/scenarios/neonatalicu.html
    March 01, 2014 - Instructor Comments The case represents teamwork failure, a missing shared mental model, poor communications … , and failure of conflict resolution.

52. Final Progress Report: Reduction of Nephrotoxic Medication-Associated Acute Kidney Injury in Children (pdf file)
    healthcare411.ahrq.gov/sites/default/files/2024-02/goldstein-report.pdf
    January 01, 2024 - reduction 2 Purpose A key limitation to a national reduction in healthcare associated harm is failure … develop chronic kidney disease,5-8 which puts them at risk for hypertension and progression to kidney failure … Lack of progress in safety linked to failure of spread In the decade since the release of the pivotal … Feig DI, Graham NM, et al. 3-5 year longitudinal follow-up of pediatric patients after acute renal failure … Childhood acute renal failure: 22-year experience in a university hospital in southern Thailand.

53. Advanced Methods in Delivery System Research – Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #4: Formative Evaluation
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar04/formative_evaluation_webinar.pptx
    July 15, 2013 - views on: Usefulness or value of intervention Barriers and facilitators to implementation success or failure … refinements to implementation strategy Can provide working hypotheses on implementation success / failure

54. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/patient-safety/resources/learning-lab/index.html
    February 01, 2024 - Tools included process mapping, swim lane diagrams, functional resonance analysis method, failure modes … Failure to Rescue Patient Safety Learning Lab (FTR PSLL) Principal Investigator: George Blike, M.D … Failure to rescue event mitigation system assessment: a mixed-methods approach to analysis of complex … To address the specific safety failure of FTR, hospitals have introduced new tools and processes (e.g … reductions in anesthesia medication errors in operating rooms in order to address three sources of failure

55. Home Mechanical Ventilators: Protocol Appendix A (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/hmv-protocol-appendixa.pdf
    October 11, 2017 - 20526 17 *Spinal Cord Injuries/ 41566 18 *Obesity Hypoventilation Syndrome/ 991 19 *respiratory failure … Neuromuscular Disease*" or Obesity or "obstructive lung disease*" or "Pulmonary fibrosis" or "respiratory failure … Neuromuscular Disease*" or Obesity or "obstructive lung disease*" or "Pulmonary fibrosis" or "respiratory failure … Neuromuscular Disease*" or Obesity or "obstructive lung disease*" or "Pulmonary fibrosis" or "respiratory failure … Neuromuscular Disease*" or Obesity or "obstructive lung disease*" or "Pulmonary fibrosis" or "respiratory failure

56. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
    September 01, 2014 - 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 … 0.412 PSI Post-Op Hemorrhage or Hematoma (PSI 9) 20,691 32,750,000 0.632 PSI Post-Op Respiratory Failure

57. TeamSTEPPS Fundamentals Course: Module 3. Communication | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
    March 01, 2019 - As these data illustrate, failure to communicate effectively as a team significantly increases the risk … Say: Lack of communication among department staff can lead to failure to: Sharing information with … Failure to seek input from the patient.

58. Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/research/publications/search.html?page=0
    January 01, 2024 - Successful approaches to learn from diagnostic quality and develop strategies to reduce harm from diagnostic failure

59. Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/research/publications/search.html
    January 01, 2024 - Successful approaches to learn from diagnostic quality and develop strategies to reduce harm from diagnostic failure

60. Tool: Advocacy and Assertion | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/teamstepps-program/curriculum/mutual/tools/advocacy.html
    June 01, 2023 - Failure to use advocacy and assertion has been frequently identified as a primary contributor to the