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Showing results for "failure".

321. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/assess-resident-RTI-slides.pptx
     June 01, 2021 - Assessment of RTI 4 Case 1: Sandy 75-year-old resident Has moderate dementia and congestive heart failure … treatments. ‹#› Assessment of RTI 15 Case 3: Peter 83-year-old resident History of congestive heart failure … He is having a heart failure exacerbation. He has bacterial pneumonia and needs antibiotics.

322. IQI, PSI, AND PDI RATES GENERATED BY THE AHRQ WINDOWS QI SOFTWARE (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2b_combo_ratesgenbywin.pdf
     March 01, 2016 - #15 Acute Myocardial Infarction (AMI) Mortality Rate 6 52 0.11538462 0.06068963 IQI16 IQI #16 Heart Failure … #8 Perioperative Hemorrhage or Hematoma Rate 0 0 - 0.00462178 PDI9 PDI #9 Postoperative Respiratory Failure … Postop Physiologic and Metabolic Derangement Rate 0 0 - 0.00046997 PSI11 PSI #11 Postop Respiratory Failure … Rate 176 0.00496390238 PQI7 PQI #7 Hypertension Admission Rate 21 0.0005913537 PQI8 PQI #8 Heart Failure … Postoperative Physiologic and Metabolic Derangement Rate 0.00047 PSI #11 Postoperative Respiratory Failure

323. 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

324. 73. For the Patient Unwilling To Quit (Continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide73.html
     October 01, 2014 - Fear of failure. Weight gain. Lack of support. Depression. Enjoyment of tobacco.

325. 125. Treatment Recommendations: Medications (Continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide125.html
     October 01, 2014 - However, it is difficult to draw firm conclusions from prior failure with a medication.

326. 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

327. 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

328. 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.

329. 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

330. 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

331. 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.

332. 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…

333. 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.

334. 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

335. 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

336. 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.

337. 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.

338. 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

339. 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

340. 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.