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Total Results: 1,922 records

Showing results for "failure".

341. Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
     April 01, 2021 - Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors . … Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors .

342. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
     November 29, 2004 - Metformin was used by 27.2 percent of those with congestive heart failure, and by 16.6 percent of those … significantly reduces the risk of subsequent adverse events including heart attacks, strokes, renal failure … or procedures is also common in outpatient practice10 Errors of omission in diabetes care include failure … A congestive heart failure diagnosis was assigned to any adult patient with diabetes who had two or … CHF=congestive heart failure. COPD=chronic obstructive pulmonary disease (emphysema).

343. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-slides.html
     September 01, 2017 - showing16 active medications during the report week, active high-risk diagnoses of pneumonia and renal failure … worsened urinary incontinence within 7 days of report date and two active high-risk diagnoses: renal failure …   Age DNR,DNH, MOLST, or POLST Order in Place Dehydration Circulatory Problems * Renal Failure … in Observation Stays or ED Visits or Hospital Visits Total Counts Congestive Heart Failure … ED Visits or Hospital Visits Total Counts Asthma Circulatory Problems Hypertension or Renal Failure

344. Head of Bed Elevation or Semirecumbent Positioning Literature Review | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/head-bed-elevation-lit-review.html
     January 01, 2017 - Study findings showed four factors to be independently associated with VAP: an organ system failure index … analysis identified four factors to be independently associated with VAP (p<0.05): an organ system failure … An organ system failure index of 3 or greater (AOR=16.1; 95% CI, 6.1 to 42; p<0.001), a premorbid lifestyle … analysis identified four factors to be independently associated with VAP (p<0.05): an organ system failure … An organ system failure index of 3 or greater (AOR=16.1; 95% CI, 6.1 to 42; p<0.001), a premorbid lifestyle

345. Tool: SSA (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/head-bed-elevation-litreview.docx
     January 01, 2017 - Study findings showed four factors to be independently associated with VAP: an organ system failure index … analysis identified four factors to be independently associated with VAP (p<0.05): an organ system failure … An organ system failure index of 3 or greater (AOR=16.1; 95% CI, 6.1 to 42; p<0.001), a premorbid lifestyle … analysis identified four factors to be independently associated with VAP (p<0.05): an organ system failure … An organ system failure index of 3 or greater (AOR=16.1; 95% CI, 6.1 to 42; p<0.001), a premorbid lifestyle

346. 151. Treatment Recommendations: Medications-Clonidine | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide151.html
     October 01, 2014 - Rebound hypertension —When stopping clonidine therapy, failure to reduce the dose gradually over a period

347. Table 28. Logistic regression of characteristics associated with utilization of education and case management visits by adults with diabetes or cardiovascular disease. | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap6tab28.html
     December 01, 2017 -   Other chronic conditions 1.57 0.002 Hypertension 0.87 0.164 Renal disease/failure

348. Table 27. Utilization of education and case management (ECM) visits among adults with diabetes or cardiovascular disease by patient characteristics. All project sites. Fisca | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap6tab27.html
     December 01, 2017 - CVD and diabetes 1.5 44.2% 3.4 Hypertension 1.1 36.9% 3.0 Renal disease/failure

349. Learning From Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-1.html
     September 01, 2023 - Successful approaches to learn from diagnostic quality and develop strategies to reduce harm from diagnostic failure

350. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
     June 03, 2008 - cause-and-effect diagram is a standard process improvement tool for facilitating identification of potential failure … increased clinical volume and/or perception of workload 18 Escalation of care: e.g., delay or failure … more senior physician or nurse 14 Recognition of change in clinical status: e.g., delay or failure … the MM&I conference presented a case in which a postoperative patient experienced respiratory failure

351. Wound Classification (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar6_pu_woundassesst.pdf
     April 01, 2011 - Slough 34 © Ayello, 2013 3 Necrotic Tissue (Eschar) 35 Eschar © Ayello, 2013 4 Skin Failure … – Some people now say this is skin failure at life’s end 36 Selecting Dressings and Treatment … Assessment Terms How To Measure a Wound Depth Epithelial Tissue Slough Necrotic Tissue (Eschar) Skin Failure

352. 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/impmaterials.html
     June 01, 2017 - high-risk diagnoses (e.g., CHF, MI/angina, pneumonia/bronchitis, COPD, dehydration, UTI, infection, renal failure … Congestive heart failure Yes |___| No |___| B. Diabetes Yes |___| No |___| C. … Renal failure Yes |___| No |___| K.

353. CAHPS® Moving Forward: Innovations in Tools and Research Webcast (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-moving-forward-cleary-slides.pdf
     March 01, 2010 - measures, including those for related to the care of acute myocardial infarction (AMI), congestive heart failure … hospitals’ care and discharge planning associated with lower 30-day readmission rates for AMI, heart failure … associated with fewer inpatient care complications, especially pressure ulcers, post-operative respiratory failure

354. Diagnostic Safety as a Challenge for Healthcare Leadership | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-1.html
     June 01, 2021 - Leadership To Improve Diagnosis: A Call to Action Diagnostic Safety as a Challenge for Healthcare Leadership Previous Page Next Page Table of Contents Leadership To Improve Diagnosis: A Call to Action Diagnostic Safety as a Challenge for Healthcare Leadership Why Are Leaders Essential to Diagnos…

355. Part 3: National Quality Strategy Priority—Effective Treatment | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs5.html
     June 01, 2018 - 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

356. Designing & Delivering Whole-Person Transitional Care The Hospital Guide to Reducing Medicaid Readmissions Webinar 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/aspire_webinar1/aspire_webinar1.ppt
     January 01, 2011 - Patients with readmission risks are not limited to Medicare Limited, Diagnosis-Specific Focus Heart failure … 19.2%) and 45-64 (21.6%) are higher than Medicare all-cause readmission rates (17.3%) Medicaid heart failure

357. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - On the failure side (Figure 1), the causal tree, which is constructed retrospectively, represents … Near Misses: Investigating Recovery and Near Failure Recovery, whether planned or unplanned,28 is an … The failure to transcribe the order occurred at the pharmacy, largely due to lack of pharmacy understanding … Moving from understanding recovery to learning from the failure to the point of recovery is likely to … In Hospital B, the focus of the human factors visit was failure of staff to adhere to fall prevention

358. Introduction to the Quality Indicators Best Practices Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
     June 02, 2025 - PSI 10 Postoperative Physiologic and Metabolic Derangement Rate • PSI 11 Postoperative Respiratory Failure … Mortality Rate • PDI 08 Perioperative Hemorrhage or Hematoma Rate • PDI 09 Postoperative Respiratory Failure

359. 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.

360. Peterson, Pamela | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumpete.html
     October 01, 2014 - Peterson's long-term career goal is to improve outcomes for patients with heart failure through comparative