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Showing results for "failure".
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www.ahrq.gov/research/findings/final-reports/stpra/stpraexh10.htmlApril 01, 2018 - drinking prior to the operation 0.13 to 0.30 Event 642 Fail to protect patient effectively (failure
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www.ahrq.gov/research/findings/final-reports/ptmgmt/evaluation-table3a.htmlJuly 01, 2018 - common chronic conditions are defined as asthma, cardiovascular disease, depression, diabetes, heart failure
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_7-implementation.pptxJuly 01, 2023 - Reviewing reports of root cause analyses and other types of defect investigations like failure modes … What were the causes of the failure? … imagines that the project has failed and brainstorms all of the reasons that could have led to this failure … The team then develops plans to mitigate those reasons for failure. How Should This Tool Be Used? … Level of Concern 1 = lowest level to 5 = greatest level Action Steps To Prevent Failure What can I do
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_7-implementation.pptxJuly 01, 2023 - Reviewing reports of root cause analyses and other types of defect investigations like failure modes … What were the causes of the failure? … imagines that the project has failed and brainstorms all of the reasons that could have led to this failure … The team then develops plans to mitigate those reasons for failure. How Should This Tool Be Used? … Level of Concern 1 = lowest level to 5 = greatest level Action Steps To Prevent Failure What can I do
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www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap5tab17.htmlDecember 01, 2017 - uncontrolled 2.4% 3.0% 0.0% Hypertension 1.3% 1.5% 0.2% Congestive heart failure
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www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumkhar.htmlOctober 01, 2014 - Assess quality management characteristics by conducting a Failure Mode Effects and Criticality Analysis
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdfJanuary 20, 2008 - Individually, one active failure or latent condition may not threaten patients, but they can align to … However, failure to recognize and address the system context in which clinicians provide patient care … These individuals work daily within the system and provide authoritative information regarding its failure … Communication failure: Basic components, contributing factors, and the call for structure. … Failure mode and effect analysis: A practical guide; Plymouth Meeting, PA: Emergency Care Research
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdfJanuary 01, 2004 - Observation data were used for flow charting the medication use process, identifying failure modes, … and estimating the likelihood of failure mode occurrence as solution generation. … Next, observations were used to confirm the occurrence of failure modes on a day-to- day basis. … Lastly, the human factors approach to the observations led to potential solutions for failure modes … Challenges with the performance of failure mode and effects analysis in healthcare organizations: an
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Walsh_74.pdfMay 28, 2008 - Failure to perform some parts of the medication regimen. 4. Failure to follow clinical advice. 5. … Failure to report information to providers. 6. … Failure to adhere to followup.31 Gandhi, et al., used medical record review and patient report to … At what level in the process did the primary failure occur? … Additional levels where failure occurred? PROCESS LEVELS 1.
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Risk-Based Patient Safety Metrics (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdfMarch 25, 2008 - In the context of patient safety, errors are defined as a failure of a planned action to be completed … Wrong site surgeries are known to be preventable through use of the universal protocol.48 Failure to … A nurse might be directed to administer a diuretic to a patient who is in congestive heart failure on … A brief look at the new look at complex system failure, error, safety, and resilience. … Safety in the operating theatre - Part 2: Human error and organisational failure. -
www.ahrq.gov/hai/tools/mvp/modules/technical/intro-early-mobility-slides.htmlFebruary 01, 2017 - Early intensive care unit mobility therapy in the treatment of acute respiratory failure. … Early intensive care unit mobility therapy in the treatment of acute respiratory failure. … Early intensive care unit mobility therapy in the treatment of acute respiratory failure.
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool1.htmlMarch 01, 2013 - discharge process, borrowing methodologies from engineering to define the RED, such as process mapping, failure … The result of hospitals' failure to ensure an effective transition has included adverse events, high … Medicare will reduce payments to hospitals with "excess readmission rates" for heart attacks, heart failure
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool1.htmlMarch 01, 2013 - discharge process, borrowing methodologies from engineering to define the RED, such as process mapping, failure … The result of hospitals' failure to ensure an effective transition has included adverse events, high … Medicare will reduce payments to hospitals with "excess readmission rates" for heart attacks, heart failure
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www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/practices.htmlApril 01, 2020 - Clinical Decision Support Result Notification Systems Education and Training Peer Review Failure
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/improvement-facilitator-guide.pdfNovember 01, 2019 - Another example of a technical problem would be failure to administer needed antibiotics to septic … Therapy SAY: A common antibiotic prescribing error that should be a target for improvement is failure … ceftriaxone and azithromycin for possible community-acquired pneumonia and furosemide for possible heart failure … In this case, the diagnosis is highly likely to be heart failure, which can be associated with low-grade
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide5.htmlOctober 01, 2022 - similarly, flawed implementation of an excellent VTE prevention protocol will result in mediocrity and failure … Effective implementation of the VTE prevention protocol addresses the first four failure modes discussed … LMWH) needs to be spelled out, and the mechanisms and responsibility for dosing adjustments for renal failure … Usability is immensely important, and success or failure may hinge on it. 2 It is far more effective
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide5.htmlOctober 01, 2022 - similarly, flawed implementation of an excellent VTE prevention protocol will result in mediocrity and failure … Effective implementation of the VTE prevention protocol addresses the first four failure modes discussed … LMWH) needs to be spelled out, and the mechanisms and responsibility for dosing adjustments for renal failure … Usability is immensely important, and success or failure may hinge on it. 2 It is far more effective
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www.ahrq.gov/research/findings/final-reports/stpra/stpraexh11.htmlApril 01, 2018 - Criticality Birnbaum Fussell– Vesely Event 642 Fail to protect patient effectively (failure
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt4.htmlMarch 01, 2020 - Slide 44 Renal Failure Among Inpatient Stays With Diabetes Image: Bar chart shows percentage of … hospitalizations for diabetes with renal failure. … Renal failure. Peripheral vascular disease. Paralysis. … Environmental health: Any Dx in CCS 128 (asthma), 127 (COPD), 131 (respiratory failure), 122 and 132 … Renal Failure: Any Dx in CCS 157 (acute) or CCS158 (chronic).
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/aspire_webinar2/aspire_webinar2.pptxJanuary 01, 2015 - Top 10 Medicare Dx: CHF Sepsis COPD Arrythmia Pneumonia UTI Acute renal failure AMI Complication of … Discharge Diagnoses: Mood disorders Schizophrenia Diabetes Chemotherapy Sickle cell Alcohol Sepsis Heart Failure
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