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Showing results for "failure".

401. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
     March 27, 2008 - ” • Failure to have complete information available (x-ray, lab, or pathology reports). … • Failure to correlate available information. • Production/time pressures, including case urgency … variety of reasons, such as poorly designed systems, inadequate training, communication errors, and failure … Of those five cases, one was caused by failure to properly identify the patient when printing MRI images … Two cases involved failure to properly describe lesions; the NYSSIPP protocol dictates that such confusion

402. Module-3-Implementation-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-implementation-guide.pdf
     June 02, 2025 - 1 Implementation Guide - Module 3 Understanding your Workflow Processes to Prepare for Systems Change Module Purpose This module continues the discussion of the steps necessary for systems change to support the implementation of automatic referral with effective care coordination. Topics include the “w…

403. Learning From Defects Through Sensemaking: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
     December 01, 2017 - System Failure Cascade 1,2 Image: Four slices of Swiss cheese presented with a red arrow lining up … Each hole represents a system failure; together the holes ultimately allow a patient to suffer.

404. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
     May 05, 2008 - proximal cause of an adverse event, organizational factors can create the circumstances in which a failure … Not doing so could result in the reasons for success or failure of an intervention remaining unclear … Safety in the operating theatre – Part 2: Human error and organisational failure.

405. | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/publications/search.html?page=2
     September 01, 2023 - Successful approaches to learn from diagnostic quality and develop strategies to reduce harm from diagnostic failure

406. Final Progress Report: Improving Patient Safety by Examining Pathology Errors (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/raab-report.pdf
     January 01, 2025 - We used the IOM’s definition of medical error: the failure of a planned action to be completed as intended … anatomic pathology diagnostic error, but it does not limit error to those events caused by cognitive failure … Process mapping and failure modes and effects analysis (FMEA) was used to determine the manner by which … We also lacked the ability to measure all variables that affected success or failure. … We experienced failure, or only variable success, in some of the single-site interventions and at some

407. Lafleur, Joanne | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumlafl.html
     October 01, 2014 - Lafleur, Joanne Summaries of Independent Scientist (K) Awards Summaries of recently funded projects for Independent Scientist and Mentored Clinical Scientist Development K Awards. Institution: University of Utah Grant Title: Knowledge Engineering for Decision Support in Osteoporosis Grant Number: K08…

408. Final Progress Report: Medication Management at Home: Patient-Identified Processes and Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/minnitti-report.pdf
     January 01, 2024 - What are the common failure modes associated with the patient process for managing medications, and … which failure modes have the greatest negative impact on patient safety from the patients’ perspectives … pathways: medication nonadherence, prescriber-patient miscommunication, patient medication error, failure … Phase 2: Patient Focus Groups We intended to use a Failure Mode and Effects Analysis (FMEA) to identify … They shared their ideas in the larger group; each possible failure was captured on a flip chart.

409. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - backdrop to the therapeutic interaction.2 It also created a locked-in paralysis for all concerned when failure … sharp-end” blame for mistakes; that incentivized learning by fully disclosing information about mistakes, failure … Thus, in many medical situations, failure to provide the correct intervention causes harm to the patient … Attempting to anticipate and prevent adverse events through safety design is known as “failure modes … ability to foresee potential failures in their design. 11 Designs are then adjusted to make failure

410. Final Progress Report: Medications at Transitions and Clinical Handoffs (MATCH) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/noskin-report.pdf
     January 01, 2024 - potentially be the first opportunity to identify and resolve a discharge medication reconciliation failure

411. USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ppe-covid19-audit-tracking-tool-userguide.pdf
     April 01, 2021 - USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities Introduction This user guide p…

412. Final Progress Report: Cancer Patient Safety Learning Laboratory (CaPSLL): Preventing Clinical Deterioration in Outpatients (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/weinger-france-report.pdf
     January 01, 2024 - A common cause of preventable harm is the failure to detect and appropriately respond to clinical deterioration … December 27, 2023 CaPSLL Final Report PURPOSE A common cause of preventable harm is the failure … In the hospital setting, “failure to rescue” (FTR) is a recognized safety failure.1 3 4 To address FTR … be generalizable to other institutions and to other high-risk outpatient populations (e.g., heart failure … Barriers and Facilitators to HRO HRO Principle Barriers Facilitators Preoccupation with failure

413. Final Progress Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
     January 01, 2024 - Risk Assessment Tool Healthcare systems have traditionally relied on root cause analysis (RCA) and failure … The ST-PRA team then quantifies the probability of failure or the frequency of occurrence for each event … Tables that provide evidence- based error rates, at-risk behavior rates, and failure rates for capturing … differences in scores may also suggest that leaders need to apprise frontline staff of technology failure … The Scorecards represent a tool for shared understanding of the failure pathways that lead to harm,

414. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Intr…

415. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Why Checklists for Diagnosis Are Not Performing as Expected Previous Page Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Introduction Rationale for Use C…

416. Chapter 8. Continue To Improve, Hold the Gains, and Spread the Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide8.html
     May 01, 2016 - Maintain and Spread the Gains After successfully addressing the failure modes and putting in place

417. Chapter 8. Continue To Improve, Hold the Gains, and Spread the Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide8.html
     May 01, 2016 - Maintain and Spread the Gains After successfully addressing the failure modes and putting in place

418. Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
     August 01, 2022 - three individual factors identified were chronic medical conditions, substance abuse, and delay and/or failure

419. Final Progress Report: Changes in Hospital Care Organization and Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/kutney-lee-report.pdf
     January 01, 2024 - Two primary patient outcomes were studied, including 30-day mortality and failure-to-rescue. … Using the patient discharge data, two primary outcome variables were examined: 30-day mortality and failure-to-rescue … their nurses’ educational composition was associated with changes in surgical patient mortality and failure-to-rescue … proportion of baccalaureate- prepared nurses were associated with reduction in 30-day surgical mortality and failure

420. Final Progress Report: Investigating Failures of Notification and Monitoring in Outpatient Care: the Safety Promotion Action Research and Knowledge Network (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/sarkar2-report.pdf
     January 01, 2024 - record review study of 5,434 randomly sampled patients, Casalino et al reported that the incidence of failure … 7.1%.42 However, this study only included selected medical practices that agreed to participate, so failure … to inform rates may be limited by selection bias, leading to potentially underestimated rates of failure … Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results.