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Showing results for "failure".

61. Learn-From-Defects-Facilitator-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - Sensemaking calls for staff to work through the failure, identifying the latent and active contributors … A knowledge-based failure happens when a person is unable to apply existing knowledge to new situations … To accomplish the same work, Sensemaking uses the Discovery Form, the Root Cause Analysis, the Failure … the failure. … On this worksheet, you see both a failure and a recovery side.

62. 130-Ss-Swiss-Cheese-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
    April 01, 2025 - for MRSA Prevention: Targeting SSI Learning From Defects: Applying the “Swiss cheese model” of System Failure … Commentary Slide Number and Slide Learning From Defects: Applying the “Swiss Cheese Model” of System Failure … this presentation are to review the definition of a defect, review the “Swiss cheese model” of system failure … In an active failure, their action directly contributes to the event. … Latent failures are the “holes in the system”—the weaknesses that create conditions for an active failure

63. Final Progress Report: Improving ED Quality and Safety by Enhancing Operations and Quality Management (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/khare-report.pdf
    January 01, 2024 - Fifty-one failure points were identified across four door-to-balloon time phases. … Failure Mode and Effects Analysis (FMEA) and Failure Modes, Effects, and Criticality Analysis (FMECA) … are methods designed to identify potential failure modes of a process. … , the frequency, consequence, and existence of any safeguards against each failure. … causes of each failure, its frequency, its impact on time-to-PCI, and safeguards was created.

64. Final Progress Report: Safety Advancement in the Emergency Department (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
    January 01, 2024 - It was determined that the three processes for improvement shared similar features and failure modes … Pre-implementation surveillance was conducted to establish baseline process failure rates. … to order lab(s) Wrong lab(s) ordered Delay or failure to order Wrong study ordered Delay or failure … to perform test Delay or failure to perform study Wrong study performed Study performed on wrong … to report results Delay or failure to act on results Delay or failure to report results Delay or

65. Exhibit 12. Probability of an intervention reducing the risk of surgical site infection (SSI) by interventions targeting component failure points individually | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh12.html
    April 01, 2018 - intervention reducing the risk of surgical site infection (SSI) by interventions targeting component failure … to prepare skin appropriately 0.1250 0.0938 0.0625 0.0313 Gate 239 Antibiotics related failure

66. Sustainability and the Premortem Tool: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-slides.html
    December 01, 2017 - Brainstorm contributing factors that led to this failure. … Slide 8: Premortem Exercise Step 2 Generate the reasons for this failure to sustain improvements … Spend 10 minutes recording the reasons that could cause this failure. … Slide 10: Premortem Exercise Step 4 Prioritize your list of potential reasons for failure. … Target the potential risks for failure to achieve sustainment goals.

67. Sustainability and the Premortem Tool: Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-fac-notes.html
    December 01, 2017 - The idea is to brainstorm for possible failure points in order to address them. … In step three, identify the concerns that would be raised by each identified potential cause for failure … Use the scale shown here to rank your team’s concerns about each failure. … 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.

68. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
    January 01, 2024 - , likely frequency of the failure, and likelihood that the failure would be detected. … Meetings to identify failure modes and their effects and to prioritize failure modes for the current … if the failure occurred), occurrence (how often does this occur), and likelihood to detect the failure … Hidden symptoms of failure. … Failure almost certain. History of failures.

69. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - Sensemaking tools include— • Discovery Form • Root Cause Analysis • Failure Mode and Effects Analysis … • A rule-based failure occurs when a person does not carry out a procedure or protocol correctly or … Sensemaking calls for teams to collaboratively seek a solution to the failure identified on their L … the failure. … On this worksheet, you see both a failure and a recovery side.

70. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
    August 01, 2022 - Could this type of communication failure occur in the future during normal working conditions? … EQUIPMENT DEVICE FAILURE Was all necessary equipment available? … EQUIPMENT DEVICE FAILURE Was all equipment functioning properly?  … EQUIPMENT DEVICE FAILURE If applicable, was this incident reported to the FDA?       … EQUIPMENT DEVICE FAILURE Was there a recall on this device?      

71. Facilitator Guide: Sustainability and the Premortem (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem_facnotes.docx
    December 01, 2017 - allows teams to reflect on how the project might fail before it starts and build in practices to prevent failure … The idea is to brainstorm for possible failure points in order to address them. … Use the scale shown here to rank your team’s concerns about each failure. … 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.

72. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/modules/identify/notes.html
    December 01, 2012 - The Failure Mode and Effects Analysis tool provides a way to conduct a step-by-step analysis staff can … A failure mode and effects analysis is different from a root cause analysis, in that the failure mode … It looks at human failure, technical failure, and organizational failure. … the failure. … On this worksheet, you see both a failure and a recovery side.

73. Fundamental Concepts for Understanding Probability | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking2.html
    September 01, 2022 - example, an 80-year-old man with hypertension and lower extremity edema who is worried about heart failure … The clinician might explain the low likelihood of heart failure, the impact of results of a BNP test, … not performing the test by stating, “Someone like you has about a 2 percent chance of having heart failure … If we do a BNP test and it’s abnormal, that chance of heart failure would rise to about 8 percent.”  

74. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4g_combo_psi10-postopmetaderangement-bestpractices.pdf
    May 20, 2016 - hospitalized patients experienced problems with glucose control (if diagnosed with diabetes) or renal failure … Manage Prevention Strategies for Postoperative Patients Avoid risk factors for acute renal failure … • Produce monthly glycemic management outcome and renal failure reports and use to provide group … Prevention of postoperative acute renal failure. J Postgrad Med 2002;48(1):64- 70. 8. … Diagnostic evaluation of the patient with acute renal failure. In Berl T, Bonventre JV, eds.

75. TAKEheart Learning Community Webinars | Agency for Healthcare Research and Quality
    www.ahrq.gov/takeheart/training/learning-community-webinars/index.html
    December 01, 2022 - addressing the needs of traditionally underserved populations, including women and patients with heart failure … Bryant , BSN RN, Cardiac Rehab/Heart Failure Nurse Manager, Prairie Heart Institute at HSHS St. … Enhancing Care for Heart Failure Patients in Your Cardiac Rehab Program Hicham Skali , MD, MSc, TAKEheart … evidence-based insights and practical solutions to help programs improve recruitment and care of heart failure

76. Enhancing Care Coordination | Agency for Healthcare Research and Quality
    www.ahrq.gov/takeheart/training/care-coordination/index.html
    April 01, 2023 - Rehab Patients Improving Support for Women Who Need Cardiac Rehabilitation Enhancing Care for Heart Failure … Improving Support for Women that Need Cardiac Rehabilitation (PDF, 394 KB) Enhancing Care for Heart Failure … evidence-based insights and practical solutions to help programs improve recruitment and care of heart failure … embedded video: https://www.youtube-nocookie.com/embed/R5DFbDzdlIM Video: Enhancing Care for Heart Failure … Cardiac Rehabilitation Program (59:22) Slides: TAKEheart Affinity Group: Enhancing Care for Heart Failure

77. Table 16A: Outcome Indicators by County Socioeconomic Status | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
    December 01, 2012 - Obstructive Pulmonary Disease 3,519 5,067 4,082 3,643 4,844 3,662 Congestive Heart Failure … Obstructive Pulmonary Disease 3,701 5,391 4,267 3,933 5,153 3,860 Congestive Heart Failure … Obstructive Pulmonary Disease 3,010 4,015 3,562 2,768 3,826 3,105 Congestive Heart Failure … or Chronic Obstructive Pulmonary Disease 678 969 886 623 866 710 Congestive Heart Failure … Obstructive Pulmonary Disease 4,709 6,184 5,410 4,618 5,702 4,899 Congestive Heart Failure

78. Table 14B: Outcome Indicators by State Supply of Health Care Providers | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14b.html
    February 01, 2023 - Asthma or Chronic Obstructive Pulmonary Disease 4,773 3,039 4,590 3,155 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 5,044 3,212 4,824 3,376 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 3,975 2,543 3,928 2,500 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 791 648 781 651 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 5,367 4,459 5,298 4,513 Congestive Heart Failure

79. Table 16B: Outcome Indicators by State Socioeconomic Status | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16b.html
    February 01, 2023 - Asthma or Chronic Obstructive Pulmonary Disease 3,314 4,720 3,896 3,782 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 3,425 5,079 4,120 4,007 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 3,011 3,576 3,258 3,103 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 678 802 762 663 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 4,469 5,799 5,061 4,811 Congestive Heart Failure

80. Table 15B: Outcome Indicators by State Demographics | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15b.html
    February 01, 2023 - Asthma or Chronic Obstructive Pulmonary Disease 4,738 3,184 4,525 3,218 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 4,951 3,384 4,723 3,455 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 4,051 2,650 3,929 2,557 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 759 692 747 696 Congestive Heart Failure … Asthma or Chronic Obstructive Pulmonary Disease 5,588 4,348 5,366 4,438 Congestive Heart Failure