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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.pdf
June 02, 2025 - or equipment or attached appliance
(cane, walker, crutch, O2) – improper use
X X
Equipment failure
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/clinical-care/clinicalcare_slides.pptx
September 03, 2014 - The failure of staff to recognize clinical signs of infection also places a patient at higher risk.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Alexander_10.pdf
January 20, 2008 - shortfalls.41, 42, 43
Limitations
A limitation of this study is the possibility of bias due to the failure
-
www.ahrq.gov/sites/default/files/2024-07/col-report.pdf
January 01, 2024 - because some treatments
have severe side effects (e.g., stroke, coronary heart disease (CHD), VTE), failure
-
www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/ncepcr-webinar-person-centered-care.pptx
June 27, 2024 - observations and personal experience
Facilitators and barriers of program implementation
Success and failure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
January 01, 2003 - Examples of breaks in policy
Transient Working Conditions
61
included failure to verify new medication
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
December 01, 2004 - This results, in part, from failure to gain prior cooperation of
the practice administrators in the
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schillinger.pdf
January 01, 2004 - 17%
21%
13% 13%
Advances in Patient Safety: Vol. 2
208
Inaccuracy in patients’ reports, or failure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
March 01, 2004 - MEDMARX in nontraditional active and passive
surveillance contexts such as root-cause analyses (RCA), failure
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pdf
June 01, 2014 - nephrologist is important for patients with progressive chronic kidney
disease who are approaching kidney failure … Quality and Disparities Report
■ Patients who begin nephrology care more than a year before kidney failure
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/womenhealth/2014nhqdr-womenhealth.pptx
January 01, 2020 - Indicators for angina, asthma, bacterial pneumonia, chronic obstructive pulmonary disease, congestive heart failure … Hospitalizations for chronic conditions include diabetes and congestive heart failure.
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight12.pdf
January 01, 2020 - How are CHIPRA quality demonstration States improving perinatal care? Evaluation Highlight No. 12
The CHIPRA Quality
Demonstration Grant Program
In February 2010, the Centers for Medicare &
Medicaid Services (CMS) awarded 10 grants,
funding 18 States, to improve the quality of
health care for children enrolled …
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.docx
January 01, 2013 - Return on Investment Tool
Return on Investment Estimation
What is the purpose of this tool? When your hospital invests in a new program, quality improvement intervention, or technology, leaders often need to know what kind of financial return the investment will yield. A return on investment (ROI) analysis is a way to…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/f1-returnoninvestment.pdf
January 01, 2009 - INSTRUCTIONS: Return on Investment Estimation
AHRQ Quality Indicators Toolkit
INSTRUCTIONS
Return on Investment Estimation
What is this tool? When your hospital invests in a new program, quality improvement
intervention, or technology, management often wants to know what kind of financial return it
will…
-
www.ahrq.gov/cahps/quality-improvement/improvement-guide/3-are-you-ready/index.html
February 01, 2020 - Section 3: Are You Ready To Improve?
July 2015
Contents
3.A. Cultivating and Supporting QI Leaders
3.B. Organizing for Quality Improvement
3.C. Training Staff in QI Concepts and Techniques
3.D. Paying Attention to Customer Service
3.E. Recognizing and Rewarding Success
References
Download Se…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
January 01, 2013 - Return on Investment Tool
Return on Investment Estimation
What is the purpose of this tool? When your hospital invests in a new program, quality improvement intervention, or technology, leaders often need to know what kind of financial return the investment will yield. A return on investment (ROI) analysis is a way to…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Patey.pdf
January 01, 2004 - Developing a Taxonomy of Anesthetists’ Nontechnical Skills (ANTS)
325
Developing a Taxonomy of Anesthetists’
Nontechnical Skills (ANTS)
Rona Patey, Rhona Flin, Georgina Fletcher,
Nicola Maran, Ronnie Glavin
Abstract
Safety research in high-reliability industries, such as aviation, has clearly shown
that t…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Williams_115.pdf
June 19, 2008 - The Rural Physician Peer Review Model©: A Virtual Solution
The Rural Physician Peer Review Model©:
A Virtual Solution
Josie R. Williams, MD; Kathy K Mechler, MS, RN, CPHQ; R.B. Akins; John R. Holcomb, MD;
Laura K. Gelderd, RN, BSN; R. Kim Clay; Tracy L. Adams; Janine C. Edwards, PhD
Abstract
Evaluating …
-
www.ahrq.gov/sites/default/files/publications/files/cdifftoolkit.pdf
September 01, 2012 - Failure to assess your organization’s readiness for the change at multiple levels can lead to
unanticipated … patients
on redundant antibiotic combinations
Defined daily doses
Length of stay
Clinical failure—reinstitution … pseudocholelithiasis
Gentamicin IV 3 mg/kg x1
dose
No adjustment for initial
dose needed for renal
failure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/presentations/2008update-full/slides.ppt
August 01, 2009 - Fear of failure.
Weight gain.
Lack of support.
Depression.
Enjoyment of tobacco. … However, it is difficult to draw firm conclusions from prior failure with a medication. … Rebound hypertension – When stopping clonidine therapy, failure to reduce the dose gradually over a period