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Showing results for "failure".

41. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - Failure Mode and Effects Analysis. Probabilistic Risk Assessment. Causal Tree Worksheet. … Sensemaking calls for staff to work through the failure, identifying the latent and active contributors … the failure. … On this worksheet, you see both a failure and a recovery side. … Culture, such as a failure because of inappropriate deference to physicians.

42. Final Progress Report: Leveraging Existing Assessments of Risk Now (LEARN) Final Report (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
    January 01, 2025 - Medium- to high-risk failure modes and failure mode causes were cataloged. … FMEAs that define how “critical” a failure might be are sometimes referred to as Failure Modes and Effects … and failure mode causes 3. … Category Failure Mode Summary Failure Mode FMEA 1 FMEA 2 FMEA 3 FMEA 4 FMEA 5 Total … Event Definition: Make one failure mode and one failure cause a single entry 4.

43. Final Progress Report: Clinical Prediction of Hepatotoxicity & Comparative Hepatic Safety of Medications (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/lo-report.pdf
    January 01, 2024 - Keywords: hepatotoxicity, acute liver failure, liver injury 2. … Classification, etiology, and considerations of outcome in acute liver failure. … Acute liver failure in the United States. Semin Liver Dis 2003;23:217-26. 7. … Reuben A, Koch DG, Lee WM, Acute Liver Failure Study G. … Thrombocytopenia in acute liver failure (ALF): A marker of multi-organ system failure and poor prognosis

44. Heart Failure Admissions Down but Hospital Deaths Higher in First Year of COVID-19 - Infographic (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/heart-failure-hospital.pdf
    January 01, 2019 - Heart Failure Admissions Down but Hospital Deaths Higher in First Year of COVID-19 - Infographic This … Heart Failure Admissions Down but Hospital Deaths Higher in First Year of COVID-19 Key: API = Asian

45. Transitions of Care | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html
    June 01, 2018 - Measures of transitions of care include: Hospitalized adult patients with heart failure who were … failure who were given complete written discharge instructions, by sex and race/ethnicity, 2005-2013 … Importance: Heart failure is the most frequent hospital discharge diagnosis in the older adults. … Trends: From 2005 to 2013, the percentage of hospitalized adult patients with heart failure who … For heart failure and COPD, low share is defined as ≤7% and high as ≥29%.

46. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/131-ss-swiss-cheese.pptx
    April 01, 2025 - Review the “Swiss cheese model” of system failure. … Prevention | Surgical Services The Swiss Cheese Model Types of Failures: Swiss Cheese Model1 active failure … Consequences A study by Tucker found that nurses encounter almost one system failure every hour (6.5 … The Swiss cheese model depicts system failure. Multiple factors contribute to patient outcomes. … Learning from failure in health care: frequent opportunities, pervasive barriers.

47. PowerPoint Presentation: Premortem for Sustainability
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem.pptx
    December 01, 2017 - The idea is to brainstorm for possible failure points in order to address them. 3 Preparing To Lead1 … to sustain improvements Spend 10 minutes recording the reasons that could cause this failure Ask your … Use the scale shown here to rank your team’s concerns about each failure. 9 Premortem Exercise Step … ASK: What can your team implement to avoid or mitigate these failure points? … SAY: Target potential risks for failure in order to achieve success in sustainment.

48. Final Progress Report: Risks of Inaccurate or Incomplete Preoperative Assessments in Freestanding ASCs (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/kupka-report.pdf
    January 01, 2024 - Determining the potential effect on the patient should the failure occur. 6. … Developing strategies so that: a. failure can be prevented; b. the rate of failure can be reduced; … Failure-mode and effects analysis in improving a drug distribution system. … Failure Mode and Effect Analysis: An Application in Reducing Risk in Blood Transfusion. … Failure Mode And Effect AnalysisTM: A Technique to Prevent Chemotherapy Errors.

49. 30-Day Readmission Rates to U.S. Hospitals, 2010 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/readmission-rates.pdf
    June 02, 2025 - , infection, or burn patients with these common diagnoses was readmitted: 25% Congestive heart failure … 22% Schizophrenia 22% Acute and unspecified renal failure patients with these less frequent … readmissions than other payers Procedure: Amputation of lower extremity Diagnosis: Congestive heart failure

50. Part 2: Trends in Priorities of the Heckler Report—Care for Cardiovascular Diseases | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part2-cvd.html
    June 01, 2018 - Importance: Early detection and treatment of high blood pressure can prevent heart failure, kidney failure … Admissions for Congestive Heart Failure Adult admissions for congestive heart failure per 100,000 population … Importance: Racial disparities in care for congestive heart failure have been observed. … Trends: From 2002 to 2013, the rate of admission for congestive heart failure among adults decreased … Congestive heart failure. Abdominal aortic aneurysm repair.

51. Final Progress Report: Risk Assessment of Pediatric Emergency Transfers (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/holl-report.pdf
    January 01, 2025 - Failure Modes Effects and Criticality Analysis (FMECA) The Failure Mode Effects and Criticality Analysis … For each failure mode identified, the cause (e.g., human factor, equipment failure) was assessed. … The frequency of each failure mode was estimated as well as the consequence of each failure mode. … chance of failure mode C1 Little Little impact on the chance of failure mode C2 Some Some impact on … Failure Mode Effects Analysis.

52. Final Topic Refinement Document: Home Mechanical Ventilators (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
    October 01, 2017 - the home through a noninvasive interface for the population of patients with chronic respiratory failure … Draft analytic framework for home mechanical ventilators Background Chronic respiratory failure … Many disease conditions may contribute to chronic respiratory failure including, but not limited to … Mechanical ventilation is used to treat chronic respiratory failure. … There is considerable variability regarding the continuum of severity of chronic respiratory failure.

53. Tool: Premortem (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/premortem-tool.docx
    January 01, 2017 - The team then develops plans to mitigate these reasons for failure. … · “Spend the next 10 minutes writing down all the reasons you believe this failure occurred. … The team will then develop plans to mitigate these reasons for failure. … Please spend the next 10 minutes writing down all the reasons you believe this failure occurred. … REASONS FOR FAILURE What could have caused this?

54. Early Mobility in the Intensive Care Unit: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-slides.html
    February 01, 2017 - Early activity is feasible and safe in respiratory failure patients. … Early activity is feasible and safe in respiratory failure patients. … Early activity is feasible and safe in respiratory failure patients. … Early activity is feasible and safe in respiratory failure patients. … Early activity is feasible and safe in respiratory failure patients.

55. Fundamental Concepts for Understanding Cognitive Load | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load2.html
    August 01, 2024 - 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 … Finally, they use germane cognitive load to pull in congestive heart failure diagnostic schemas to compare … this patient’s clinical presentation with their typical representation of a patient with heart failure … during the diagnostic reasoning process to accurately diagnose this patient with decompensated heart failure

56. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
    January 01, 2024 - Key Words: failure modes and effects analysis, oral medication, antineoplastic drug, medication error … We proposed to convene an interdisciplinary team to identify, analyze, and prioritize failure modes … high-priority targets based on their likelihood of failure, severity, and detectability. … They identified the causes and effects of each failure mode and ranked each failure mode based on its … Each failure mode was prioritized by using a weighted voting technique.

57. 136-Ss-Premortem-Tool (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/136-ss-premortem-tool.docx
    April 01, 2025 - Replacement, and Spinal Fusion Surgeries Projects often fail, and many factors may contribute to this failure … interventions that can be included in the intervention that will mitigate these possible reasons for failure … Reasons for Failure: “What Could Have Caused This?” … Level of Concern: 1 (Lowest Concern) to 5 (Highest Concern) Action Steps To Prevent Failure: “What

58. Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-woods_79.pdf
    May 30, 2008 - Failure events in Risk Bins I and II become the focus for targeted attention. … of failure mode CP3 Significant Significant impact on the chance of failure mode CP4 Certain Almost … In this study, these groups are called “failure categories.” … Representative cases are then selected from the failure categories. … Failure modes and effects analysis in healthcare.

59. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2024.xlsx
    January 01, 2024 - The tables include the relative frequencies by type of device, by device defect, failure or use error … Description Device Event Description Percentage Frequency Unknown 57.5% 22,873 Device defect or failure … , including HIT 29.6% 11,791 Use error 8.9% 3,534 Combination or interaction of device defect or failure … Percentage No Harm Frequency Harm Percentage Harm Frequency Unknown 95.1% 5,134 4.7% 253 Device defect or failure … 92.5% 3,604 7.2% 263 Use error 87.5% 1,255 13.0% 189 Combination or interaction of device defect or failure

60. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
    July 01, 2023 - Discovery Form Safety Issues Worksheet Root Cause Analysis Learn From Defects Form Failure … identification Defects Human/active failure Latent/system conditions Ways to identify … defects or failure Staff Safety Assessment Status of Safety Issues Worksheet Discovery … Form Root Cause Analysis Failure Mode and Effects Analysis Probabilistic Risk Assessment … The left side of the tree is labeled the failure side, and a small part of the right side is labeled