Results

Total Results: 1,922 records

Showing results for "failure".

261. Final Progress Report: Cardio-HIT Phase II (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/kmetik-otoole-report.pdf
     January 01, 2024 - recognized, ambulatory care physician performance measures for coronary artery disease and heart failure … practices submitted clinical performance data to a data warehouse for coronary artery disease and heart failure … separate analyses: an exception sample for validation of exception criteria and an apparent quality failure … Electronic medical records for patients in the exception, apparent quality failure, and measure met … Automated review of electronic health records to assess quality of care for outpatients with heart failure

262. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
     January 01, 2005 - These include probabilistic risk assessment, process mapping, qualitative analyses, failure mode and … Failure mode and effects analysis (FMEA) Failure mode and effects analysis (FMEA) is an ongoing quality … If employed before new processes are implemented, FMEA can identify potential failure modes. … Applications of Failure Analysis to hospital quality appraisal. … A portion of the failure mode and effect analysis (FMEA) Figure 1.

263. Final Progress Report: Probabilistic Risk Assessment Chicago Transplant Inquiry Study (PRACTIS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/cook-report.pdf
     January 01, 2024 - The underlying tensions that create the opportunity for this form of failure remain at the center of … the transplantation process, and it is likely that these tensions will give rise to other forms of failure … Delineating these new forms of failure is not within the scope of the current project, but they could

264. CAUTI Sustainability: Embedding CAUTI Policies, Using Data to Monitor Proress and Hardwiring CUSP Principles | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
     December 01, 2017 - The Power of Measuring Results If you do not measure results, you can not tell success from failure … If you can not reward success, you are probably rewarding failure. … If you can not recognize failure, you can not correct it. … It is the result of preparation, hard work, and learning from failure.” General Colin L. … On the way down, failure feeds on itself.

265. National Quality Strategy Priority: Effective Treatment | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part3-nqs5.html
     October 01, 2015 - 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

266. AHRQ's RED Toolkit Leads to Lower Readmissions, Better Care Transitions in Two Texas Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201420.html
     November 01, 2014 - The 586-bed VBMC-Harlingen's baseline 30-day readmissions rate for patients with heart failure, acute … discharge—and then-looming Medicare payment reductions for hospitals with readmissions for heart attack, heart failure

267. 5 Tk1 T5-Sample Policy Letter Final (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK1_T5-Sample_Policy_Letter_final.pdf
     October 01, 2016 - development of Clostridium difficile infections, the emergence of multi-drug resistant organisms, antibiotic failure

268. 5 Tk1 T5-Sample Policy Letter Final (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK1_T5-Sample_Policy_Letter_final.docx
     October 01, 2016 - development of Clostridium difficile infections, the emergence of multi-drug resistant organisms, antibiotic failure

269. Final Progress Report: Process Reliability and Organizational Learning in Home Health Care (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
     January 01, 2025 - IN HOME HEALTH CARE Findings from this review were used to refine the fault tree structure, derive failure … as necessary and unavoidable – indicating no exception to recommended home health practice or other failure … (s) Resulting from care process failure(s) - contributing causes 15.2% 69.6% 17.4% 30.4% 13.0% … The dominant failure mode identified was care planning, implicated in 69.6% of cases, followed by failures … Failure to identify this may result in care plans that are incompatible with patients’ abilities to

270. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - A “medical error” is defined as the failure of a planned action to be completed as intended (error … Safety barriers act to prevent a health care provider from committing an active failure or by mitigating … the effect of an active failure.8 In a systems approach, error reduction is achieved by strategically … Advances in Patient Safety: Vol. 2 432 Failure mode and effects analysis (FMEA) The management … Potential failure mode and effects analysis (FMEA), reference manual, 3rd ed.

271. Final Progress Report: Older adult safety while receiving home health services after hospital discharge (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/arbaje-report.pdf
     January 01, 2024 - multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure … Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. … Discharge education improves clinical outcomes in patients with chronic heart failure. … Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure … Rehospitalization in a national population of home health care patients with heart failure.

272. NPSD Dashboards | Agency for Healthcare Research and Quality
     www.ahrq.gov/npsd/data/dashboard/index.html
     September 01, 2024 - Dashboard Details the type of device; type of device by residual harm to the patient; device defect, failure … , or user error; device defect, failure, or user error by residual harm to the patient; type of health

273. Ambulatory Pediatric Patient Safety Learning Lab: Pursuing Safe Healthcare at Home | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/ambulatory-pediatric-long-desc.html
     January 01, 2025 - in-home medication review, medication administration observation, parent surveys, simulations, and failure … Ambulatory Patient Safety Learning Lab: Failure Modes and Effects Analysis for Management of Type 1 Diabetes

274. Final Progress Report: Risk Assessment of the Testing Processes of Access Community Health Network (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/eder-report.pdf
     January 01, 2024 - of the management of critical abnormal labs, but this was not ultimately accomplished due to our failure … 42% The chart audit data may overestimate deficiencies in communicating test results to patients; failure … which there was one or more documentation Test Type failures Testing step where the first failure … Community Health Network Eder 9 Total patients for which there was at least one documentation failure … to diagnose, which frequently involves failure to appropriately follow up on abnormal test results

275. Slide 1
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
     January 01, 2013 - , experience, history and tradition The Culture of Safety and Assessment of Harm 7 Believe that failure … to follow guidelines may cause harm Built in alerts Consequences for failure to implement The Case … a high reliability organization, an organization that is mindful because it : Is preoccupied with failure … MIV Tube feeding Pressors with minimal titration Chronic Lasix Mildly sedated or drowsy Respiratory failure

276. A Future Vision for Better Diagnostic Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load5.html
     May 01, 2024 - Consider the hospitalist admitting the patient with congestive heart failure and, unbeknownst to them … and can appropriately engage in dual-process thinking; they realize that their patient has both heart failure

277. Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cuspmvp-slides.html
     February 01, 2017 - Slide 26: Premortem Exercise Step 2 Generate the reasons for failure. … Brainstorm reasons you believe this failure occurred. … Slide 27: Premortem Exercise Step 3 Prioritize your list of potential reasons for failure.

278. Preventing CAUTIs in the ICU Setting
     www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module-1-slides.pptx
     September 01, 2015 - 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%) Overview ‹#› AHRQ

279. Module-3-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-slides.pdf
     February 09, 2022 - categories that your redesigned processes will need to address 23 Current Workflow Map: A Tool Failure … patients eligible for CR Patient objection to referral Referral process failures Cardiologist failure

280. TeamSTEPPS® Diagnosis Improvement: Infographic (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-infographic.pdf
     February 01, 2022 - TeamSTEPPS® Diagnosis Improvement: Infographic TeamSTEPPS® for Diagnosis Improvement AHRQ Publication No. 22-0015 February 2022 References 1. National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: National Academies Press; 2015. https://doi.org/10.17226/21…