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Showing results for "failure".

101. Tools for Sustainability: Premortem and Scorecard: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-slides.html
     February 01, 2017 - Respect probability of failure over time. … Brainstorm contributing factors that led to this failure. … Spend 10 minutes recording the reasons that could cause this failure. … Slide 19: Premortem Exercise Step 4: Prioritize your list of potential reasons for failure. … Target the potential risks for failure to achieve sustainment goals.

102. Technical Specifications for Timely Fluid Bolus for Children With Severe Sepsis or Septic Shock (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-technical-specifications.pdf
     June 02, 2025 - • Children with chronic renal failure as defined by any mention of chronic renal failure or end stage … • Children with congestive heart failure as defined by any mention of congestive heart failure.

103. NICU Family Information Packet, Appendix B, Gastroesophageal Reflux (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ger.pdf
     June 02, 2025 - ■ Failure to thrive is usually NOT associated with physiologic GER in premature infants. … Symptoms Of Pathologic GER ■ Failure to thrive due to malnourishment.

104. C1 Prioritization Worksheet (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
     June 02, 2025 - Hematoma   PSI 10 Postoperative Physiologic and Metabolic Derangement PSI 11 Postoperative Respiratory Failure … Conditions Quality Indicator Composite Conditions Composite IQI 15 AMI Mortality   IQI 16 Heart Failure … Surgery Volume PDI 08 Perioperative Hemorrhage or Hematoma Rate PDI 09 Postoperative Respiratory Failure

105. Building Self-Empowered Teams for Improving Safety in Postoperative Pain Management (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Singh-R_68.pdf
     April 20, 2008 - Identify all the possible failure modes at each step. e. … The microsystem view provides a natural structure for identifying failure modes. … The questionnaire contains 153 failure modes. … Failure modes were then ranked according to their means. … Practice-based failure modes and effects analysis for system enhancement.

106. Staff Safety Assessment
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
     January 01, 2006 - Safety Assessment Discovery Form Safety Issues Worksheet Root Cause Analysis Learn from Defects Form Failure … tools 3 The Relationship Between CUSP and Sensemaking1,2,3 Concept CUSP Sensemaking Defect or failure … identification Defects Human/active failure Latent/system conditions Ways to identify defects or failure … Safety Assessment -Status of Safety Issues Worksheet -Discovery Form -Root Cause Analysis -Failure

107. TeamSTEPPS Mutual Support Facilitator Participant Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/module-4-mutual-support-participant-worksheet.pdf
     June 02, 2025 - Discuss the causes of reluctance or failure to seek support when needed. 3. … Discuss ~4 minutes ▪ What might cause reluctance or failure to seek support when it is needed?

108. Implementation Module Handouts (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-module-handouts.docx
     July 01, 2023 - What were the reasons for or causes of the failure? … Failure Reason What could have been the cause? … Level of Concern 1 = lowest to 5 = greatest Action Steps To Prevent Failure What can be done differently … Ideal Proximity 1 = presently ideal to 5 = far from ideal Action Steps To Prevent Failure What can be

109. Final Progress Report: Evaluating treatment options and patterns of care in early pregnancy failure (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/dalton-report.pdf
     January 01, 2024 - Final Progress Report: Evaluating treatment options and patterns of care in early pregnancy failure … Title Page Evaluating treatment options and patterns of care in early pregnancy failure Study Team: … Treatment patterns for early pregnancy failure among Michigan Medicaid participants. … Provider knowledge, attitudes and treatment preferences for early pregnancy failure. … Early pregnancy failure management among family physicians. Fam Med 2012. In press.

110. Implementation Guide for Automatic Referral: Building, Implementing, and Troubleshooting and Automatic Referral for Cardiac Rehabilitation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/implementing-automatic-referral-implementation-guide.pdf
     March 01, 2023 - • Failure to understand the principles of change management. … • Failure to assign specific roles for data gathering and data entry. • Failure to do a full walk-through … • Failure to time the training to when users can optimally absorb it. … . • Failure to assure that providers actually complete training. • Failure to have a full-dress rehearsal … • Failure to organize charting tools so care team can easily find them. • Failure to limit the amount

111. New Healthcare Quality Indicator from AHRQ Aimed at Addressing Maternal Morbidities | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/maternal-health-indicators.html
     October 01, 2024 - experience the highest rates of deaths and illness from complications of labor or delivery, such as renal failure … , eclampsia, heart failure, problems with anesthesia, sepsis, aneurysms, and more. … definitions of maternal health complications during labor and delivery, such as coagulopathy and renal failure

112. Sepsis | Agency for Healthcare Research and Quality
     www.ahrq.gov/topics/sepsis.html
     address sepsis, a systemic inflammatory response to infection that results in tissue damage and organ failure

113. Grant Closeout Requirements | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grant-mgmt/closeout.html
     October 01, 2024 - and Certification (FIS) Final Research Performance Progress Report (F-RPPR) Submission Requirements Failure … Return to Contents Failure To Comply Failure to submit the required reports in a timely manner may result

114. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - Identify process and control system failure modes. … Examples of summary failure modes and effects analyses Process Failure mode Downstream controls Failure … dependencies between errors, and misestimated failure rates. … Failure mode and effects analysis. JONA 1997;27(12);19–26. 12. Gladstone J. … Examples of summary failure modes and effects analyses Figure 1.

115. Final Progress Report: Developing a patient-centered model of the risk of perioperative complications in spine surgery (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/ratliff-report.pdf
     January 01, 2024 - Therefore, errors in coding or failure in preoperative comorbidity capture are sources of potential … The next-highest performance was shown in congestive heart failure symptoms (AUC 0.75) and pneumonia … 519 <1 Renal failure 1,565 0.7 Congestive Heart Failure (CHF) 1,182 1.0 Congestive Heart Failure (CHF … (CHF) 6,286 3.4 Congestive Heart Failure (CHF) 21,345 3.6 Pneumonia 6,501 3.5 Pneumonia 15,940 2.7 Deep … 1,587 <1 Renal failure 5,588 <1 Pulmonary Embolism (PE) 12,083 6.5 Pulmonary Embolism (PE) 6,247 1.1

116. Final Progress Report: Risk Models To Improve Long-Term Care Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
     January 01, 2024 - Failure Modes and Failure Rates. … Examples of Summary Failure Modes and Effects Analysis (FMEA) Process Failure Mode Downstream Controls … Any equipment failure that can affect the top-level event. … Q:0.95 G t 448 MAR failure Q:0.335 E t788 MAR not ... Q:0.328 E t738 MAR check ... … number of failure combinations that dominate the model.

117. Priority Areas Identified by the U.S.-Mexico Border Commission: Summary & Definitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part4-summ.html
     October 01, 2015 - Renal failure. Peripheral vascular disease. Paralysis. … 661 (substance use) Environmental health: Any Dx in CCS 128 (asthma), 127 (COPD), 131 (respiratory failure … Renal Failure: Any Dx in CCS 157 (acute) or CCS158 (chronic).

118. Penn Medicine Chester County Hospital Implements AHRQ Toolkit to Reduce Readmissions | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201506.html
     April 01, 2015 - "We initially implemented RED for congestive heart failure patients on our telemetry unit," said Carli … Based on the success with congestive heart failure patients—the notable reduction in readmissions and … Since RED's hospital-wide implementation, the average readmission rate for congestive heart failure is

119. Chronic Kidney Disease | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/kidney.html
     June 01, 2018 - Measures of Effective Treatment of Chronic Kidney Disease Process: Nephrology care before kidney failure … nephrologist is important for patients with progressive chronic kidney disease who are approaching kidney failure … Patients who begin nephrology care more than a year before kidney failure are less likely to begin dialysis … nephrologist is important for patients with progressive chronic kidney disease who are approaching kidney failure … Patients who begin nephrology care more than a year before kidney failure are less likely to begin dialysis

120. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - and “What is the effect of each failure?” … When a failure is identified, two options exist: reduce the probability of failure to an acceptable level … Failure mode and effects analysis. Healthcare Risk Control System. … Heath care failure mode and effects analysis. In Medication Errors. 2nd ed. … Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction. 2nd ed.