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www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/health-promotion-education/strategy6r-reminder-systems.html
March 01, 2020 - Failure to consider these questions is likely to undermine the success of the reminder system. … Failure to keep clinic appointments: Implications for residency education and productivity.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/mindfulness-061014.pptx
March 07, 2014 - AMP Appropriate Cure Failure 90 91 5 UP Appropriate Cure Failure 32 55 31
What is “Antibiotic Stewardship … Ceftaz Cipro
Before 79 65 63 66 84
After 87 83 81 88 94
Sheet1
Appropriate Cure Failure
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
September 01, 2014 - Iatrogenic Pneumothorax (PSI 6)
PSI Post-Op Hemorrhage or Hematoma (PSI 9)
PSI Post-Op Respiratory Failure … sample, and those with a principal diagnosis of acute
myocardial infarction (AMI), congestive heart failure … 0.412
PSI Post-Op Hemorrhage or
Hematoma (PSI 9)
20,691 32,750,000 0.632
PSI Post-Op Respiratory Failure
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
November 30, 2013 - .
• High-risk diagnosis associated with transfer risk: congestive heart failure (CHF),
myocardial infarction … infection, dehydration, circulatory problems (includes vascular disease, venous and
arterial ulcer), renal failure … • Circulatory Problems
On-Time Preventable Hospital and ED Visits Electronic Reports 4
• Renal Failure … urinary incontinence documented within 7
days of report date and two active high-risk diagnoses of renal failure … Preventable discharge
diagnoses include congestive heart failure, pneumonia, urinary tract infection,
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
December 01, 2003 - the NHS to be more open in the way it deals with
professional errors and “to recognize that honest failure … traveled through the Incident
Decision Tree, the more likely the underlying cause is to be a systems failure … • Many cases appear to go awry from the outset because of failure to
differentiate between formally
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www.ahrq.gov/ncepcr/tools/confid-report/research-agenda.html
March 01, 2016 - Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance
Part Four: A Research Agenda To Advance the Science of Physician Feedback Reporting Systems
Previous Page Next Page
Table of Contents
Confidential Physician Feedback Reports: Designing for Optimal Impact on Performa…
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www.ahrq.gov/prevention/guidelines/archive.html
July 01, 2018 - Heart Failure
Clinical Guide / Quick Reference Guide
Consumer Version: English / Spanish
12
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/overview-slides.html
December 01, 2017 - Postoperative hemorrhage, respiratory failure, accidental puncture/laceration. … Slide 52: Premortem Exercise
Step 2
Generate the reasons for failure. … Spend 10 minutes recording the reasons you believe this failure occurred. … Slide 53: Premortem Exercise
Step 3
Prioritize your list of potential reasons for failure.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt4.pptx
January 01, 2014 - Severity index based on comorbidities 1.02 0.89 1.06 0.93
Amputations 1.57 1.52 0.95 0.92
Renal failure … A higher percentage of Hispanics in border counties with an inpatient stay for diabetes had renal failure … (listed as any diagnosis), compared with non-Hispanics in border counties.
44
Renal Failure
Hispanic … Renal failure.
Peripheral vascular disease.
Paralysis. … -661 (substance use)
Environmental health: Any Dx in CCS 128 (asthma), 127 (COPD), 131 (respiratory failure
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability.pptx
December 01, 2015 - The Power of Measuring Results
17
If you do not measure results, you can not tell success from failure … If you can not reward success, you are probably rewarding failure. … If you can not recognize failure, you can not correct it. … It is the result of preparation, hard work, and learning from failure.”
General Colin L. … On the way down, failure feeds on itself.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - Clinical or operational events or situations that you do not want to happen again
Examples of defects
Failure … Learning from failure in health care: frequent opportunities, pervasive barriers.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report.pdf
January 01, 2022 - into four groups: those with a principal diagnosis of
acute myocardial infarction, congestive heart failure … CI
Both DVT and PE developed during
stay
3 21649 0.0 0.0 – 0.0
Other AEs
AE attributed to failure … Other AE attributed to failure to communicate laboratory,
pathology, imaging, and physiologic test … or disruption, or
graft failure
Dental injury
21
Module Adverse Event (AE) Outcome
High … Other Other occurrences
Renal failure
Unplanned transfer
Ventilator support (non-OR)
8.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
January 01, 2022 - into four groups: those with a principal diagnosis of
acute myocardial infarction, congestive heart failure … CI
Both DVT and PE developed during
stay
3 21649 0.0 0.0 – 0.0
Other AEs
AE attributed to failure … Other AE attributed to failure to communicate laboratory,
pathology, imaging, and physiologic test … or disruption, or
graft failure
Dental injury
21
Module Adverse Event (AE) Outcome
High … Other Other occurrences
Renal failure
Unplanned transfer
Ventilator support (non-OR)
8.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
January 01, 2022 - into four groups: those with a principal diagnosis of
acute myocardial infarction, congestive heart failure … CI
Both DVT and PE developed during
stay
3 21649 0.0 0.0 – 0.0
Other AEs
AE attributed to failure … Other AE attributed to failure to communicate laboratory,
pathology, imaging, and physiologic test … or disruption, or
graft failure
Dental injury
21
Module Adverse Event (AE) Outcome
High … Other Other occurrences
Renal failure
Unplanned transfer
Ventilator support (non-OR)
8.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6c.pdf
March 01, 2017 - For example, a patient whose chart includes an
unfamiliar reference to “congestive heart failure” might … think it refers to an actual
failure rather than a manageable heart condition
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www.ahrq.gov/takeheart/about/case-for-cardiac-rehab/index.html
December 01, 2022 - individuals who have:
Had a heart attack
Stable angina
Received angioplasty or stent
Heart failure
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www.ahrq.gov/talkingquality/measures/setting/physician/examples.html
September 01, 2019 - Education and counseling for patients with certain conditions (e.g., hepatitis, heart failure).
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
September 01, 2017 - High-risk diagnoses associated with transfer risk (congestive heart failure, myocardial infarction, … Renal failure.
Diabetes.
Anemia.
Gastroenteritis. … Rule out congestive heart failure.
Rule out deep vein thrombosis.
Respiratory. … Potentially preventable discharge diagnoses follow:
Congestive heart failure.
Pneumonia. … Potentially preventable discharge diagnoses follow:
Congestive heart failure.
Pneumonia.
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www.ahrq.gov/sites/default/files/2024-10/glance-report.pdf
January 01, 2024 - paraplegia
by 70%, cerebrovascular disease by 70%, myocardial infarction by 65%, congestive
heart failure … Twenty-five percent (congestive heart failure) to 76% (PCI) of hospitals
classified as low-quality hospitals … For decubitus ulcer,
failure-to-rescue, and postoperative pulmonary embolism or DVT, the intraclass- … for preoperative risk factors,
transmural myocardial infarction (adj OR 7.90; p<0.001), respiratory failure … (adj OR
6.02; p<0.001), renal failure (adj OR 7.15; p<0.001), and stroke within 24 hours (adj OR
4.09
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13.html
December 01, 2012 - Pulmonary Disease
5,029
4,037
3,180
4,196
3,954
3,070
3,401
4,560
Congestive Heart Failure