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Total Results: 362 records

Showing results for "failure".

41. Leveraging Cultural Change to Reduce Urinary Catheter Use | Agency for Healthcare Research and Quality
    pbrn.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

42. Tool 1: Readmission Data Analysis and Interpretation (xls file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
    September 20, 2016 - 120 500 24% 5% Sepsis 100 500 20% 4% Psychosis 80 400 20% 3% COPD 70 300 23% 3% Renal Failure … Cellulitis w/o MCC 20 150 13% 1% Total, Top 10 550 Total, All Readmissions 2550 22% Heart Failure … 200 1300 15% 8% COPD 30 300 10% 1% Intracranial hemorrhage 25 50 50% 1% Renal failure with CC … with MCC 15 80 19% 1% Psychosis 15 100 15% 1% UTI 15 80 19% 1% Sepsis 10 145 7% 0% Respiratory failure … 0% Medicaid Cellulitis 10 100 10% 0% COPD with MCC 5 30 17% 0% Chest pain 5 35 14% 0% Renal failure

43. TeamSTEPPS Specialty Scenarios: Neonatal ICU (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/neonatalicu.pdf
    March 19, 2014 - Instructor Comments  The case represents teamwork failure, a missing shared mental model, poor communications … , and failure of Conflict resolution.

44. Agency for Healthcare Research and Quality
    pbrn.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

45. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
    pbrn.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.

46. Organizing Quality Measures To Reduce Information Overload | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/talkingquality/translate/organize/index.html
    March 01, 2016 - , effectiveness, timeliness) Organizing Measures by Disease or Condition (e.g., congestive heart failure

47. Follow Up with Patients: Tool 6 | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/health-literacy/improve/precautions/tool6.html
    February 01, 2024 - concern (e.g., blood pressure above 140/90, weight gain of more than 2 to 3 pounds in a day for heart failure … sample of patients who should have received followup after a recent visit (e.g., patients with heart failure

48. Tool: Advocacy and Assertion | Agency for Healthcare Research and Quality
    pbrn.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

49. Mourning the Loss of Deputy Director David Meyers, M.D. | Agency for Healthcare Research and Quality
    pbrn.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.

50. TeamSTEPPS Specialty Scenarios: Ambulatory Care (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/ambulatory.pdf
    March 19, 2014 - Scenarios Ambulatory Care 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.

51. Situation Monitoring (Instructor Guide) (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.pdf
    February 12, 2014 - They are the result of team members’ failure to: • Share information with the team; • Request … Here are some examples of where failure can occur in the STEP process: • Status of the Patient: … Failure to take a patient’s vital signs • Team: Failure to assist a team member who you know is … overloaded • Environment: Failure to know where the necessary equipment is stored • Progress … Toward Goal: Failure to call a huddle and update the team when the plan has changed

52. Using TeamSTEPPS to Create Change ... (pt 2/3)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps-webinar-080917.pptx
    January 01, 2017 - leverage social/peer pressure to help drive change. 24 Change is Not Easy If you want change, failure … is part of the deal Not failure of the mission, but failure in route.

53. TeamSTEPPS® 2.0 Leadership Briefing | Agency for Healthcare Research and Quality
    pbrn.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

54. Participating in the CAHPS Home and Community-Based Services Survey Database | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/cahps/cahps-database/hcbs-database/participate.html
    January 01, 2024 - Failure to follow these guidelines will result in your data not being included in the database.

55. Strategies for Improving Patient Experience with Ambulatory Care: Service Recovery Programs (pdf file)
    pbrn.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

56. Specific Tools To Support Change (pdf file)
    pbrn.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?)

57. Strategy 6C: OpenNotes | Agency for Healthcare Research and Quality
    pbrn.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.

58. Participating in the CAHPS Health Plan Survey Database | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/cahps/cahps-database/hp-database/participate.html
    December 01, 2023 - Failure to follow these guidelines will result in your data not being included in the database.

59. Introduction to the Quality Indicators Best Practices Tool (pdf file)
    pbrn.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

60. Download Files: Long-Term Care | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/teamstepps/longtermcare/downloads.html
    April 01, 2013 - file, 14.2 MB) Sue Sheridan video on Patient Safety (Zip file, 216 MB) Team Structure All Team Failure