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Showing results for "failure".

321. Exhibit 1.19. Major Factors that Inhibit Lean Success at LHC | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit1-19.html
     November 01, 2014 - Implementing an EHR prior to redesigning processes results in failure to realize the benefits of this

322. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
     March 23, 2008 - A medical error was defined as “the failure to complete a planned action as intended or the use of a … to provide standard of care resulting in poor outcome as a result of that failure.” … “Failure to give medical care that is appropriate based on the patient’s presentation, history, and … “Failure to provide care equal to the standard of care in terms of thoroughness, timeliness.” … “Failure to provide the "standard of care" for a given medical problem to a patient in a safe and timely

323. Making Healthcare Safer IV | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs4/index.html
     May 01, 2025 - Decision Support To Prevent Medication Errors and Adverse Drug Events (Feb. 9, 2024) Report Protocol Failure … Journal of Patient Safety and Risk Management 2024 August 21 Patient Monitoring Systems To Prevent Failure

324. CMV_27_M3_CUSP_SSA_Premortem
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-slides.pptx
     January 01, 2017 - Safety Program for Mechanically Ventilated Patients Premortem Exercise Step 2 Generate the reasons for failure … Brainstorm reasons you believe this failure occurred. … Mechanically Ventilated Patients Premortem Exercise Step 3 Prioritize your list of potential reasons for failure

325. Leveraging Cultural Change to Reduce Urinary Catheter Use | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/leveraging-cultural-change-slides.html
     December 01, 2017 - history and tradition Slide 7 The Culture of Safety and Assessment of Harm Believe that failure … to follow guidelines may cause harm Built in alerts Consequences for failure to implement Slide … feeding žPressors with minimal titration žChronic Lasix žMildly sedated or drowsy Respiratory failure

326. Minding the Gaps: Creating Resilience in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nemeth_116.pdf
     April 27, 2008 - exist at an operating point (the circled dot symbol) within an envelope that is bounded by economic failure … Management exerts pressure to increase efficiency in order to avoid economic failure. … , create and sustain strategies that are resistant to failure, and adjust tasks and activities to maintain … Resilience engineering: Remaining open to the possibility of failure. … Resilience engineering: Remaining open to the possibility of failure.

327. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
     July 18, 2008 - screening protocol, failure to include cancer in the differential diagnosis, and inadequate followup … In these cases, common process problems included failure to order an appropriate test, create a proper … Further analysis revealed judgment error (79 percent), failure of vigilance or memory (59 percent), … Failure to diagnose is the no. 1 allegation in liability lawsuits. … Communication failure: Basic components, contributing factors, and the call for structure.

328. TeamSTEPPS Research/Evidence Base: TeamSTEPPS and Patients and Families | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/evidence-base/patients-families.html
     June 01, 2023 - Engaging patients and families to transform heart failure care.

329. Why Evaluate a Health Care Quality Reporting Project? | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/assess/why-evaluate.html
     May 01, 2019 - All participants in a report card project will reach conclusions about the relative success or failure

330. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
     April 18, 2004 - unscheduled readmission within 30 days of discharge for three Diagnosis Related Groups (DRGs) (127–Heart Failure … The three targeted DRG categories were: 127–Heart Failure (HF), 089–Pneumonia (>17 years), and 109–Coronary … Average direct costs were lower at the VA hospital for CABG patients, but were higher for heart failure … Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. … Applying the transitional care model to elderly patients with heart failure.

331. Examples of Patient Harm Related to Invasive Devices | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/section3.html
     October 01, 2015 - He was diagnosed with congestive heart failure exacerbation. … Case 2 An 82-year-old woman was admitted to the cardiac intensive care unit for congestive heart failure

332. Section 5, Table 3 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-228-section-5-table-3.pdf
     August 01, 2014 - with at least equal hemodynamic instability based on systolic blood pressure and sequential organ failure … were receiving time- and fluid- sensitive treatment, which the researchers felt might explain the failure

333. Gurses, Ayse | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumgurs.html
     October 01, 2014 - Conduct a prospective risk assessment of the potential failure modes.

334. Table 3b. Examples of Evaluation Measures; Additional Categories | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptmgmt/evaluation-table3b.html
     July 01, 2018 - common chronic conditions are defined as asthma, cardiovascular disease, depression, diabetes, heart failure

335. Organizing Quality Measures To Reduce Information Overload | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/organize/index.html
     March 01, 2016 - , effectiveness, timeliness) Organizing Measures by Disease or Condition (e.g., congestive heart failure

336. Hand Hygiene Observational Audit Tracking Tool (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
     December 01, 2021 - Hand Hygiene Observational Audit Tracking Tool Ref January 2021 KS A:B Admin February 2021 MO D:E RN March 2021 SC G:H LPN/LVN April 2021 VA J:K Med Aides May 2021 CNA June 2021 EVS July 2021 Maintenance August 2021 Dietary September 2021 SW-Rec October 2021 Rehab November 20…

337. High-Hanging Fruit: Improving Transitions in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Perry_49.pdf
     March 27, 2008 - of practitioners and settings, due to factors common to complex domains with high consequences for failure … divisions have long been viewed as necessary evils, fertile ground for error, and opportunities for failure … Failure to invest time here runs the risk of undermining embedded safety features developed ad hoc to … Communication failure: Basic components, contributing factors, and the call for structure. … Handoff strategies in settings with high consequences for failure: Lessons for health care operations

338. Final Progress Report: Reducing Risks by Engineering Resilience Into HIT for EDs (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/wears-report.pdf
     January 01, 2024 - ]; computerized provider order entry, the ‘Holy Grail’ of safety efforts, has led to new forms of failure … Politics and patient safety don't mix: understanding the failure of large- scale software procurement … Automation, interaction, complexity, and failure: a case study. … Plausibly correct, but wrong: a failure phenotype in health IT.

339. Low Tidal Volume (Lung Protective) Ventilation Literature Review | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-lit-review.html
     January 01, 2017 - Assessed risk factors for three types of organ failure (prolonged mechanical ventilation, hemodynamic … instability, and renal failure) and a prolonged stay in the ICU. … Found that tidal volumes of >10 mL/kg are risk factors for organ failure and prolonged ICU stay after … instability, and renal failure) and a prolonged stay in the intensive care unit. … , multiple organ failure, and prolonged stay in the intensive care unit.

340. References (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-litreview.docx
     January 01, 2017 - Assessed risk factors for three types of organ failure (prolonged mechanical ventilation, hemodynamic … instability, and renal failure) and a prolonged stay in the ICU. … Found that tidal volumes of >10 mL/kg are risk factors for organ failure and prolonged ICU stay after … (prolonged mechanical ventilation, hemodynamic instability, and renal failure) and a prolonged stay … , multiple organ failure, and prolonged stay in the intensive care unit.