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Showing results for "failure".

281. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereports.html
     September 01, 2017 - High-risk diagnosis associated with transfer risk: congestive heart failure (CHF), myocardial infarction … infection, dehydration, circulatory problems (includes vascular disease, venous and arterial ulcer), renal failure … Asthma or COPD UTI Sepsis or Fever or Infection Dehydration Circulatory Problems Renal Failure … urinary incontinence documented within 7 days of report date and two active high-risk diagnoses of renal failure … Preventable discharge diagnoses include congestive heart failure, pneumonia, urinary tract infection,

282. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt2.pptx
     July 01, 2015 - Hispanics and Whites had similar rates of admission for congestive heart failure. … Importance: Early detection and treatment of high blood pressure can prevent heart failure, kidney failure … Trends: From 2002 to 2012, the rate of admission for congestive heart failure among adults decreased … Hispanics had lower death rates than Whites when hospitalized for congestive heart failure and there … Importance: Diabetes is the most common cause of kidney failure.

283. Unique Challenges in Approaching Diagnostic Safety in Older Adults | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults2.html
     September 01, 2024 - Similarly, increasing age has been found to be associated with poorer diagnostic accuracy of heart failure … Heart failure. Parkinson’s disease. Stroke/transient ischemic attack. Acute myocardial infarction. … Heart failure (15%). Depression (16%). … Faulty data gathering and synthesis. 71 Improper communication (e.g., inadequate handoffs, failure to … missed on inpatient services, 73 and acute or subacute functional decline is frequently labeled as failure

284. Final Progress Report: Enhancing Stroke Prehospital and Emergency Evaluation and Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/prabhakaran-holl-report.pdf
     January 01, 2025 - High-criticality failures (e.g., failure to detect LVO, failure to use screening tools) led to the design … • Failure Mode Effects and Criticality Analysis (FMECA): The LC was asked to identify failures (weaknesses … scores were then used to calculate a Risk Prediction Number (RPN) and Criticality Number (CN) for each failure … Reducing Door-in-Door-out Times by Applying Failure Modes Effects and Criticality Analysis.

285. Enhancing Care Coordination for CR Resource Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/care-coordination-resource-guide.pdf
     November 17, 2022 - The Grady Heart Failure Program: A Model to Address Health Equity Barriers 31. … Circulation - Addressing Social Determinants of Health in the Care of Patients with Heart Failure: A … Scientific Statement from the American Heart Association This article addresses SDOH in heart failure

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

287. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
     January 01, 2024 - Next, the raw data were analyzed using content analysis, failure modes and effects analysis and variance … Analysis The raw data were subjected to hazard analyses using content analysis, failure modes, and … Being able to detect a failure and being able to fix or control it are two different things. … These seven failure modes were associated with 65 causes of those failure modes, categorized into five … All the causes were linked to one or more failure modes.

288. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
     April 22, 2004 - The conventional view is that the [health care] system is safe by design but can be degraded by the failure … modes and effects analysis (FMEA),39, 40 health care failure modes and effects analysis (HFMEA),41 … Failure mode and effect analysis: FMEA from theory to execution. … The step-by-step guide to failure modes and effects analysis. … Healthcare failure mode and effect analysis course materials (HFMEA™).

289. Cognitive Load Theory and Its Impact on Diagnostic Accuracy: Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load-theory.pdf
     May 01, 2024 - Publication No. 24-0010-3-EF. 1 e Introduction to Diagnostic Errors Diagnostic errors, or “the failure … A hospitalist is admitting a patient with presumed new heart failure from a busy emergency department … They also begin to recall from their long-term memory the pathophysiology of congestive heart failure … this patient’s clinical presentation with their typical representation of a patient with heart failure … The hospitalist diagnoses the patient with congestive heart failure.

290. Appendix A | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-apa.html
     April 01, 2018 - Effect Diagramming' 'Designing for Safety' 'Evaluation of Patient Safety Programs' 'Failure … Mode and Effects Analysis (HFMEA) 'Healthcare Failure Modes and Effects Analysis (HFMEA)'

291. Appendix 1. Bibliography of Recent Reviews of Self-Management Support Effectiveness | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptmgmt/appendix1.html
     July 01, 2018 - Multidisciplinary strategies for the management of heart failure patients at high risk for admission: … Disease management programmes for older people with heart failure: crucial characteristics which improve

292. Getting Started Laying the Groundwork Coordination for Implementing Automatic Referral & Effective Care
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-slides.pptx
     December 31, 2022 - replacement or repair, or a heart or heart-lung transplant Chronic stable angina Chronic stable heart failure … Lost track of paperwork Perception that patient won’t enroll anyway Belief that CR is not beneficial Failure … CR Eligibility not identified Referral process failures Patient objection to referral Cardiologist failure … failures and can address them as you redesign your processes. 45 Accessible Sample Fishbone Diagram Failure … Exclusive reliance on admission codes Ownership of eligibility determinations unclear Cardiologist failure

293. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - A preoccupation with failure. … The preoccupation with failure is both about preventing an isolated failure and making the system as … One hospital might experience only one or two instances of any given equipment failure. … As humans are imperfect, these systems are doomed to failure. … That viewpoint makes increased reports a system success rather than a failure.

294. Data Infographics | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/index.html
     July 01, 2025 - Versus Readmission Costs, 2020 Adult Opioid Fills by Race Expenditures for COVID-19 Care in 2020 Heart Failure … and Cost of Heart Disease Declining Hospital Costs for Seniors with Traditional Medicare 2020 Heart Failure

295. A Conceptual Framework for Studying the Safety of Transitions in Emergency Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Behara.pdf
     January 01, 2004 - These transitions, or “handovers,” are potential points of failure that have seen very little study. … These handovers are widely considered to be potential sources of failure.9, 10 Although the success … The problem of understanding how transitions contribute to the success or failure of care is compounded … , or as a contributor to the incipient failure recovery). … Handoff strategies in settings with high consequences for failure: lessons for health care operations

296. Final Progress Report: Center for Safety In Emergency Care (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/wears2-report.pdf
     January 01, 2025 - Rather than being entirely points of vulnerability, they were quite often sources of recovery from failure … Key Words Patient safety; medical failure; emergency medicine; human factors; cognitive psychology … Forgive and Remember: Managing Medical Failure. … Although the net balance of failure vs recovery is still unknown, the fact that transitions are not … Dealing with failure: the aftermath of errors and adverse events. Ann Emerg Med 2002;39(3:344-6.

297. Table 8G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8g.html
     February 01, 2023 - 2,147 s s s s   Max 13,021 10,304 12,903 15,635 s Congestive Heart Failure … 1,987 s   Max 14,022 12,938 s 14,357 7,727 11,756 13,599 Congestive Heart Failure

298. Table 8A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8.html
     February 01, 2023 -   Min 816 s s s s   Max 9,211 7,982 10,309 16,438 s Congestive Heart Failure … 668 s   Max 6,516 11,021 6,679 14,357 7,727 7,740 10,370 Congestive Heart Failure

299. Table 8E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8e.html
     February 01, 2023 -   Min s s s s s   Max 13,360 15,789 19,048 14,679 s Congestive Heart Failure … s   Max 13,055 15,821 12,381 25,806 19,672 12,818 14,829 Congestive Heart Failure

300. Table 8D: Intellectual/Developmental Disabilities Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8d.html
     February 01, 2023 -   Min s s s s s   Max 2,283 3,661 6,197 42,857 s Congestive Heart Failure … s s   Max 1,813 1,968 1,224 8,724 41,026 1,592 2,288 Congestive Heart Failure