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Total Results: 362 records

Showing results for "failure".

261. DARTNet Guided Exploration of Linkages Between Existing Health Data, Patient Reported Outcomes and PBRN Research” Webinar Presentation Slides (pdf file)
     pbrn.ahrq.gov/sites/default/files/docs/DARTNetDataWebinar.pdf
     August 18, 2015 - hyperkalemia oRate of hip, forearm or clavicle fractures on and off ACE/ARB oInstances of acute renal failure

262. CUSP Toolkit Spread Facilitator Notes | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/hai/cusp/modules/spread/notes.html
     December 01, 2012 - Solutions that are simple and designed with very little risk of failure contribute to the success of

263. Monitoring for Perinatal Safety: Electronic Fetal Monitoring (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
     May 01, 2017 - among team members related to EFM interpretation; and the fear of conflict, intimidation, and/or failure

264. AHRQ Safety Program for Perinatal Care: Safe Medication Administration
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemedication.pptx
     May 01, 2017 - Failure to Set a Volume Limit for a Magnesium Bolus Dose Leads to Harm.

265. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
     July 05, 2023 - Diagnostic errors are defined as the failure to establish an accurate and timely explanation of the patient

266. TeamSTEPPS Fundamentals Course: Module 2. Team Structure | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/teamstepps/instructor/fundamentals/module2/igteamstruct.html
     March 01, 2014 - TeamSTEPPS Long-Term Care Version : Includes a team failure video specific to long-term care.

267. Facilitator Notes | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
     December 01, 2012 - In what has been known as a blame-free culture, there is a general failure to uphold standards of care

268. Chapter 3. Developing Change: Designing the Medication Reconciliation Process | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/hospital/match/chapter-3.html
     July 01, 2022 - Linking medication reconciliation to other strategic goals (e.g., heart failure publicly reported process

269. TeamSTEPPS Implementation Guide | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/teamstepps/instructor/essentials/implguide.html
     November 01, 2018 - variety of sources, including adverse event and near-miss reports, reports of root cause analyses or failure

270. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/teamstepps/instructor/scenarios/labordel.html
     March 01, 2014 - Instructor Comments This teamwork failure is the result of a series of communication breakdowns. … Instructor Comments This teamwork failure depicts the absence of a clearly defined leader and lack

271. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - (2014) Post-Op Hemorrhage or Hematoma (PSI 9) 19,000 0.59 PSI (2014) Post-Op Respiratory Failure

272. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
     August 01, 2022 - Failure-to-rescue cases. First death experiences. Unexpected patient demise.

273. 3. What Are the Best Practices in Pressure Ulcer Prevention that We Want to Use? (continued) | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3a.html
     October 01, 2014 - Skin failure: a retrospective review of patients with hospital-acquired pressure ulcers.

274. Pressure Ulcer Prevention Toolkit (doc file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
     August 31, 2017 - ongoing complex medical care and need for management of advanced Parkinson’s disease, dysphagia, and failure

275. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
     January 01, 2023 - who received a transplant within 3 years of date of renal failure.” … 100,000 population, age 18 and over HCUP 2020 Deaths per 1,000 hospital admissions with heart failure … kidney transplant within a year of initiation USRDS 2019 Patients with treated chronic kidney failure … who received a transplant within 3 years of date of renal failure USRDS 2017 Hemodialysis patients … 100,000 population, age 18 and over HCUP 2020 Deaths per 1,000 hospital admissions with heart failure

276. Facilitator's Notes (continued) | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/teamstepps/simulation/traininggd1.html
     July 01, 2016 - are more effective when measuring overt actions or errors (acts of commission) than when measuring failure

277. TeamSTEPPS Fundamentals Course: Module 4. Leading Teams | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html
     March 01, 2019 - It is important to reinforce what went well and avoid assigning blame or failure to any individual regarding

278. Is Your Organization Ready for TeamSTEPPS™? (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-3-readiness-form.pdf
     August 01, 2005 - originate from a variety of sources, including adverse event and near-miss reports, root cause analyses or failure

279. Is Your Organization Ready for TeamSTEPPS™? (pdf file)
     pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/readiness/tsreadiness.pdf
     August 01, 2005 - originate from a variety of sources, including adverse event and near-miss reports, root cause analyses or failure

280. Final report: Realizing Improved Patient Care through Human-centered Design in the OR (pdf file)
     pbrn.ahrq.gov/sites/default/files/2024-01/joseph3-report.pdf
     January 01, 2024 - of slipping/falling/tripping), usability (e.g., malfunctioning furniture and equipment), equipment failure