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Total Results: 362 records

Showing results for "failure".

101. Accelerating Change and Transformation in Organizations and Networks (ACTION) 4 | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/research/findings/factsheets/translating/action4/index.html
     February 01, 2021 - process of implementing innovations and the contextual factors influencing implementation success or failure

102. TeamSTEPPS in Long-Term Care (LTC): Financial and Safety Benefits of Implementing TeamSTEPPS in Nursing Homes and LTC Facilities
     pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-sept2013.pptx
     January 01, 2013 - Analysis of sentinel events reported to The Joint Commission over 10 years identified communication failure … The VA’s National Center for Patient Safety database shows similar results with communication failure

103. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
     pbrn.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

104. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
     September 01, 2022 - Cross-Cutting: Health Information Technology Cross-Cutting: Other Topics Delirium Diagnostic Errors Failure … Evidence Staff Education and Training (Not reviewed) (Not reviewed) Summary of Evidence Failure

105. Search Evidence-Based Reports | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/research/findings/evidence-based-reports/search.html
     May 01, 2024 - Rapid Evidence Product Affiliation: ECRI Institute—Penn Medicine Report Status: Final Failure

106. 5. How do we measure our pressure ulcer rates and practices? | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
     October 01, 2014 - When a deep pressure ulcer develops, it usually reflects not so much the failure of an individual clinician … , but rather a system failure. … Root cause analysis is a useful technique for understanding reasons for a failure in the system.

107. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 (pdf file)
     pbrn.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

108. TeamSTEPPS Implementation Guide (pdf file)
     pbrn.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.

109. Assessing the Impact of Value-Based Purchasing Programs | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-waters.html
     February 01, 2022 - launched in 2013, levied financial penalties on hospitals with unplanned readmissions for congestive heart failure

110. Healthcare, Climate Change, Environmental Justice, and AHRQ | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/news/blog/ahrqviews/healthcare-climate-change.html
     October 01, 2021 - SHARE: More topics in this section News Newsroom Blog AHRQ Views Newsletter Events AHRQ Views: Blog posts from AHRQ leaders Healthcare, Climate Change, Environmental Justice, and AHRQ OCT 13 2…

111. TeamSTEPPS 2.0 Module 5: Situation Monitoring
     pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule5.pptx
     February 06, 2006 - Usually the loss of situation awareness is as a result of the team members failure to share information … Some of the specific examples for where failure can occur in the STEP process-- remember the STEP mnemonic … -- status of the patient, there would be a failure to take a patient's vital signs; in the team considerations … , a failure to assist a team member who you know is overloaded; environmentally, failure to know where … the necessary equipment is stored; and the progress towards the goal, a potential failure to call a

112. FileNewTemplate
     pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module9.pptx
     March 07, 2019 - minutes to think of a story related to organizational change What things were critical to the success or failure … Once you have identified an event, think about things that were critical to either the success or failure … Failure in implementing change is often due to under-communication. … Failure to implement change is often the result of undercommunicating or communicating poorly the plan

113. Issue Brief 9: Improved Diagnostic Accuracy Through Probability-Based Diagnosis (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-probabilistic-thinking.pdf
     September 01, 2022 - example, an 80-year-old man with hypertension and lower extremity edema who is worried about heart failure … The clinician might explain the low likelihood of heart failure, the impact of results of a BNP test … not performing the test by stating, “Someone like you has about a 2 percent chance of having heart failure … If we do a BNP test and it’s abnormal, that chance of heart failure would rise to about 8 percent.”

114. Accelerating Change and Transformation in Organizations and Networks III | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/research/findings/factsheets/translating/action3/index.html
     February 01, 2021 - process of implementing innovations and the contextual factors influencing implementation success or failure

115. Communication is the most important leadership trait (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/leadership-communication.pdf
     January 01, 2018 - If leaders aren’t proactively listening, chances are they are setting themselves up for failure.

116. Research on Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/diagnostic-safety/research/index.html
     March 01, 2024 - SHARE: More topics in this section Diagnostic Safety and Quality Research on Diagnostic Safety and Quality Diagnostic Safety Grants Awarded in FY 2022 Diagnostic Safety Grants Awarded in FY 2019 Tools To Improve Diagnostic Safety Re…

117. Selected Best Practices and Suggestions for Improvement (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
     November 01, 2012 - Postoperative respiratory failure is not currently part of Medicare’s Hospital Value-Based Purchasing … Also consider performing a failure mode and effects analysis to better understand the process and where

118. Toolkit for Improving Perinatal Safety | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html
     July 01, 2023 - SHARE: More topics in this section Patient Safety Patient Safety Research Summaries Patient Safety Resources by Setting Hospital Hospital Labor and Delivery Units Perinatal Safety Toolkit About the Toolkit How To Use the Too…

119. Comparative Reports on Hospitals | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/talkingquality/resources/comparative-reports/hospitals.html
     December 01, 2022 - Users can filter measures by angioplasty, blood clots, heart attack, heart failure, mother and baby,

120. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcarae Meeting (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2023.pdf
     March 01, 2024 - related to financial payouts; up to one- third of all cases that end in a claim have a diagnostic failure