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Total Results: 1,922 records

Showing results for "failure".

201. Table 17E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17e.html
     February 01, 2023 - Obstructive Pulmonary Disease 5,622 3,983 5,619 4,362 6,108 4,326 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 5,185 4,519 5,313 4,855 Congestive Heart Failure

202. Table 19G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19g.html
     March 01, 2023 - Obstructive Pulmonary Disease 5,832 4,430 4,513 5,441 4,689 5,483 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 4,378 5,982 4,711 5,551 Congestive Heart Failure

203. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
     www.ahrq.gov/downloads/pub/advances/vol2/Schiff.pdf
     January 01, 2005 - “ Suboptimal weighing “ Failure/delay to followup “ 4. … Tests (lab/radiology) Ordering Failure/delay in ordering needed test(s) Failure/delay … Followup Failure to refer to setting for close monitoring Failure/delay in timely followup/rechecking … Relationship between diagnosis failure and adverse outcomes 3. … Failure to diagnose. http://www.medical-malpractice- attorneys-lawsuits.com/pages/failure-to- diagnose.html

204. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schiff.pdf
     January 01, 2005 - “ Suboptimal weighing “ Failure/delay to followup “ 4. … Tests (lab/radiology) Ordering Failure/delay in ordering needed test(s) Failure/delay … Followup Failure to refer to setting for close monitoring Failure/delay in timely followup/rechecking … Relationship between diagnosis failure and adverse outcomes 3. … Failure to diagnose. http://www.medical-malpractice- attorneys-lawsuits.com/pages/failure-to- diagnose.html

205. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - Failure to rescue 6. Foreign body left during procedure 7. … Failure to act on the results of monitoring or testing 8. … Postoperative respiratory failure 13. Postoperative sepsis 14. … Failure to provide indicated prophylactic treatment 11. … Failure in communication 13. Equipment failure 14. Other systems failure by 7 percent.

206. Appendix G. References for Fault Tree Model Probability Estimates | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpraapg.html
     October 01, 2018 - opern prior to identifying skin lesion 0.001 Best guess (sub-TEP indicated the probability of this failure … Event235 Drape gets contamtd during opern 0.001667 From Tony, Draping-related failure=0.01, split … 0.001667 Event236 Fail to notice drape not sterilize 0.001667 From Tony, Draping-related failure … So 0.01/6=0.001667 Event237 Drape pulls bug to SS 0.001667 From Tony, Draping-related failure … From Tony Event322 Fail to notice drape has holes 0.001667 From Tony, Draping-related failure

207. Guide for Developing a Community-Based Patient Safety Advisory Council | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncilapa.html
     April 01, 2018 - team Goal: Revise patient education materials that are provided to patients with congestive heart failure

208. Evidence Base Supporting Telehealth | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/teledx-2.html
     August 01, 2020 - improves health outcomes, utilization, and cost of care for a host of chronic diseases, including heart failure

209. 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-fullreport.pdf
     May 01, 2018 - 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. 4. … 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. 4. … The overall agreement for being in the NICU, having renal failure, or having congestive heart failure

210. Final Progress Report: Improving Patient Safety by Reducing Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/strom2-report.pdf
     January 01, 2024 - Poor adherence can lead to potential or real failure of anticoagulation and threaten patient safety … Age was included as a potential confounder for the higher risk of acute renal failure with age. … All analyses preserved the matching by use of stratified failure-time analysis. … Each case-patient was followed until failure (the day of development of acute renal failure). … By our creatinine-based definition, 278 of these courses of drugs ended in acute renal failure.

211. Module 1: Overview | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod1-slides.html
     February 01, 2023 - Hemodynamic instability Acute respiratory failure Management of life-threatening laboratory abnormalities … Examples: Management of acute renal failure, IV fluids, or IV or oral bolus diuretics Fluid management … in acute respiratory failure requiring large volumes of oxygen (≥5 L/min or >50%) Slide 10

212. OR-to-ICU Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions4.html
     June 01, 2023 - protocol and the primary effectiveness outcome will be a composite measure of new-onset multiorgan failure … include in a handoff tool is vital to preventing cognitive overload, reducing the risk of communication failure … evaluation of diagnostic safety is inherent within the composite outcome measure of new-onset multiorgan failure

213. VA Provides Specialty Care in Local Offices Across the Country | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cp31307.html
     May 01, 2013 - physicians and other care providers are now being trained in specialty care areas, including heart failure … Conditions addressed include diabetes, hepatitis C, heart failure, and chronic pain. … primary care providers have often referred to specialists, including epilepsy, kidney disease/renal failure

214. Proactive Risk Assessment of Surgical Site Infections in Ambulatory Surgery Centers (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpra.pdf
     March 01, 2012 - Probability of intervention reducing risk of SSI by interventions targeting component failure points … in the processes (e.g., communication failure between health care professionals). … Failure B 1.00e-003 Gate1 Undesirable Outcome 2.00e-003 Event1 Failure A 1.00e-003 Event2 … Failure B 1.00e-003 21 Step 3. … A minimal cut set is defined as a critical path through multiple failure points.7 By identifying the

215. Clinical Inertia and Outpatient Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
     January 01, 2003 - Failure to intensify therapy in patients with elevated blood glucose, blood lipids, or blood pressure … Clinical inertia is defined as failure to intensify treatment in a patient who has not yet achieved … Such patterns of care reflect failure of one or more parts of the decision strategy (i.e., failure to … set appropriate goals, failure to initiate appropriate treatment, failure to titrate to goal). … The logic of failure. Reading, MA: Addison-Wesley; 1997. 41. Brehmer B.

216. Module on How To Apply CUSP for Mechanically Ventilated Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/cusp.html
     March 01, 2017 - CUSP Implementation Premortem Tool ( Word , 1.59 MB) Use this tool to help you assess potential failure … points, brainstorm the potential reasons for the failure, and then develop a plan to mitigate these

217. Tools for Sustainability: Premortem and Scorecard: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-fac-guide.html
     February 01, 2017 - In fact, sustaining adaptive work has a high failure rate. … The idea is to brainstorm for possible failure points in order to address them. … Use the scale shown here to rank your team’s concerns about each failure. … Ask: What can your team implement to avoid or mitigate these failure points? … Say: Target potential risks for failure in order to achieve success in sustainment.

218. Learning From Defects | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/surgery/learning-from-defects.html
     April 01, 2025 - viewers will be able to— Review the definition of a defect Review the “Swiss cheese model” of system failure

219. Case Study | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/ena-slides/case-study.html
     October 01, 2015 - Her BNP is elevated, indicating congestive heart failure. … She is demonstrating severe congestive heart failure. … Slide 138 Considerations Severe congestive heart failure Need of fluid removal Does diuresis

220. Why Is Improving Diagnosis Important? Physician and Patient Perspectives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/schiff-summit2016.pdf
     January 01, 2013 - how3iQ • Disease A repeatedly mistaken for Disease B • Bipolar disease mistaken for depression • Failure … with cognitive difficulties • Presuming chronic disease accounts for new symptoms • Lung cancer: failure … , other environmental cause • Pancreatitis from drug; carbon monoxide toxicity fail to consider • Failure