Results

Total Results: 1,954 records

Showing results for "failure".

281. 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

282. 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

283. 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.

284. 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

285. 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,

286. 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.

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. 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.

289. 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

290. Issue Brief 26: Exploration of Foundational Terminology and Paradigms for Improving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-terminology.pdf
     April 01, 2025 - the simplicity of “a correct diagnosis,” terminology and methods differ when defining success and failure … terms and perspectives that describe aspects of diagnostic success or consequences of diagnostic failure … to adequately diagnose, in which case, the harm comes from the underlying disease and is due to failure … One consequence of defining failure or problems as “errors” is a strong tendency by those unfamiliar … Diagnostic Failure A failed process or a wrong or delayed diagnosis.

291. 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

292. 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

293. 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

294. 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™).

295. 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.

296. 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.

297. 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

298. 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)'

299. 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

300. 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.