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Showing results for "failure".

441. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
     January 01, 2024 - Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety Final Progress Report Title: Effects of Extended Work Hours on ICU Patient Safety Principal Investigator: Charles A. Czeisler, Ph.D., M.D. Organization: Brigham and Women's Hospital Co-Investigators: Christopher P. Landrigan, M.D., M.P.H.…

442. Teaching Implementation Change Management | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/team/implement/teach-change.html
     February 01, 2024 - Failure to implement change is often the result of undercommunicating or communicating poorly. … If you have time, use the organizational change exercise to discuss potential causes of failure and how … While listening, they should take notes about things that were critical to either the success or failure

443. Final Progress Report: Transitional Care Medication Safety and Reducing Medical Liability: Closing the Chasm (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/corbett-report.pdf
     January 01, 2024 - generated using a comprehensive process that engaged a variety of stakeholders in focus groups and failure … Council and used the collective information generated from the stakeholder focus groups to inform a Failure … Patient Safety Advisory Council for improving hospital-to- community care transitions following the Failure

444. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-facguide.docx
     January 01, 2017 - As a group, consider all the reasons you think the failure occurred. … Slide 26 Premortem Exercise SAY: Once the potential reasons for failure have been identified, prioritize … SAY: This process raises awareness and helps the team anticipate reasons for failure and try to mitigate … Second, brainstorm with the team to determine factors which may have caused the failure of your project

445. Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.html
     February 01, 2017 - As a group, consider all the reasons you think the failure occurred. … Slide 27: Premortem Exercise Say: Once the potential reasons for failure have been identified, … Say: This process raises awareness and helps the team anticipate reasons for failure and try to mitigate … Second, brainstorm with the team to determine factors which may have caused the failure of your project

446. 3 Tk1 T5-Draft Policies And Procedures For The Antimicrobial Stewardship Program Final (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nhguide/3_TK1_T5-Draft_Policies_and_Procedures_for_the_Antimicrobial_Stewardship_Program_final.pdf
     October 01, 2016 - development of Clostridium difficile infections, the emergence of multi-drug resistant organisms, antibiotic failure

447. C1 Prioritization Worksheet (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheet.xlsx
     June 02, 2025 - Surgery Volume PDI 08 Perioperative Hemorrhage or Hematoma Rate PDI 09 Postoperative Respiratory Failure

448. QDR 2014: Chartbook for Hispanic Health Care, Part 4 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt4.pdf
     January 01, 2014 - † Respiratory includes asthma, chronic obstructive pulmonary disease, respiratory failure, and other … -Mexico Border 2014 National Healthcare Quality and Disparities Report | 105 Renal Failure  A … higher percentage of Hispanics in border counties with an inpatient stay for diabetes had renal failure … Renal Failure Among Inpatient Stays With Diabetes Source: Agency for Healthcare Research and Quality … ■ Renal failure. ■ Peripheral vascular disease. ■ Paralysis.

449. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
     January 01, 2024 - Failure to administer an ordered dose (omission error) and incorrect administration time of medication … In one study of hospitalized patients, failure to specify the controlled-release formulation was the … , we found that the same types of system failures that plague inpatient medical settings (e.g., failure

450. Final Progress Report: Creating Learning Cultures Around Mistakes for Residents (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
     January 01, 2024 - toward others Expressing feelings and concern for those in the group who make mistakes and experience failure … Systems thinking Thinking about or couching episodes of error or failure within the context of the total … Willingness to develop logics that link contextual factors to increased probability for the error or failure … than big changes that will not be readily accepted by the existing physician culture (thus leading to failure … Forgive and Remember: Managing Medical Failure. Chicago. University of Chicago Press, 1979.

451. Webinar 1: Introduction & Overview: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/guide/web1.html
     December 01, 2017 - Limited, Diagnosis-Specific Focus: Heart failure, heart attack, pneumonia, COPD, hip/knee replacement … Medicaid heart failure readmission rates are higher than Medicare rates: 29.1% versus 23.7%.

452. Advanced Methods in Delivery System Research – Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #4: Formative Evaluation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar04/formative_evaluation_webinar.pptx
     July 15, 2013 - views on: Usefulness or value of intervention Barriers and facilitators to implementation success or failure … refinements to implementation strategy Can provide working hypotheses on implementation success / failure

453. Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
     June 02, 2025 - ■ Failure to thrive is usually NOT associated with physiologic GER in premature infants. … Symptoms Of Pathologic GER ■ Failure to thrive due to malnourishment. … ■ An open ductus may lead to: – Congestive heart failure. – Pulmonary hypertension. … ■ Failure to thrive. … ■ Mortality of 30-40% from sepsis or liver failure.

454. Daily Goals During Interdisciplinary Rounds: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/daily-goals-rounds-fac-guide.html
     February 01, 2017 - Slide 5: Why Communication Matters Say: Year after year, studies show that communication failure … Sixty-three percent of reported sentinel events are related to some form of communication failure.

455. Final Progress Report: Cardiovascular Care Disparities: Safety-Net HIT Strategy (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/ferguson-report.pdf
     January 01, 2024 - Scope: Using the Congestive Heart Failure (CHF) Disease Management program within the eight- hospital … established in 2000 within this HCSD context for HIV/AIDS, Diabetes, Asthma, and Congestive Heart Failure … This approach allows for three different providers to use “CHF,” “congestive heart failure,” and “NYHA … What is the prevalence of the metabolic syndrome in ambulatory systolic heart failure patients? … J Cardiac Failure 8:suppl 1:S65. Hebert K, Arcement L, Liz D, Ferguson T, Ventura H. 2001.

456. Final Progress Report: Targeted Delivery of Multiparametric Telemetry Clinical Messages to Mitigate Alarm Fatigue - PERSEUS (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/kobayashi-report.pdf
     January 01, 2024 - of simultaneous, continuous MeTeOR acquisition of live ED unit-wide multiple-monitor datastreams; failure … rates (hardware [device failure]; network [transmission/communication failure]; software [data loss … for blinded chart review include death, severe cardiopulmonary events (cardiac arrest, respiratory failure … rates (hardware [device failure]; network [transmission/communication failure]; software [data loss … , data corruption; algorithm failure]) Task 3.3: Deliverables from continuing research conducted with

457. Module-7-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-7-slides.pdf
     November 18, 2021 - Significance Proceeding without rigorous bench testing is a common cause of implementation failure. … Implementation Team mid-day huddle until implemented • Snacks 18 Go-Live: Avoid Common Causes of Failure … 2d47b0cd80f3d9d62ff45c15b99ec49 November 2nd 1:00-2:00 pm ET TAKEheart Affinity Group: Enhancing Care for Heart Failure

458. AHRQ’s RED Toolkit Inspires Improved Patient Discharge at Nacogdoches Memorial Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201501.html
     March 01, 2015 - then-looming Medicare payment reductions for hospitals whose readmission rates for heart attack, heart failure

459. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
     January 01, 2024 - , and reports of preventable adverse events are increasing.2,3 Examples include fulminant hepatic failure … Moreover, because patient safety process errors such as (1) failure to institute preventive practices … failures to determine, document, or follow up on results of tests prior to medication initiation and failure … example, post-marketing surveillance data have suggested that rituximab can result in fulminant liver failure

460. Reviewing the Team's Performance: Debrief | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
     December 01, 2023 - It is important to reinforce what went well and avoid assigning blame or failure to any individual regarding