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Showing results for "failure".

81. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
    April 01, 2018 - not diabetic, patient (30 ≤BMI <40) Event 642 (0.2) Fail to protect patient effectively (failure … not diabetic, patient (30 ≤BMI <40) Event 642 (0.2) Fail to protect patient effectively (failure … not diabetic, patient (30 ≤BMI <40) Event 642 (0.2) Fail to protect patient effectively (failure … but not diabetic, patient (30failure

82. Hospital Readmissions: Not Just a Problem for Medicare (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hospital-readmission-problem.pdf
    June 02, 2025 - 20% 25% 30% Medicare Medicaid Knee Arthroplasty Hip Replacement PneumoniaCongestive Heart Failure … readmission rates for Medicare and Medicaid patients for acute myocardial infarction, congestive heart failure

83. Health Care Quality: How Does Your State Compare? (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/qdr-state-snapshot.pdf
    June 02, 2025 - in 2014 in three areas – avoiding sepsis in surgery patients, ensuring specialty care for kidney failure … https://nhqrnet.ahrq.gov/inhqrdr/state/select PERCENTAGE OF KIDNEY FAILURE PATIENTS WHO SAW A SPECIALIST

84. Library of PCOR Resources | Agency for Healthcare Research and Quality
    www.ahrq.gov/pcor/library-of-resources/index.html
    April 01, 2021 - search , you could find information by entering the following: All words (e.g., "congestive heart failure … An exact word or phrase in relation to another such phrase (e.g., "congestive heart failure" AND "statins … Certain words or phrases (e.g., "heart failure"). … An exact word or phrase and the author's name (e.g., "congestive heart failure" AND "statins" AND "John … An exact word or phrase and the institution name (e.g., "congestive heart failure" AND "statins" AND

85. Presentation: Program Overview
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
    January 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.

86. Webinar 2: Analyze Data and Patient/Caregiver Perspectives (Section 1 of the Guide): Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/guide/web2.html
    December 01, 2017 - Acute renal failure. AMI. Complication of device. Stroke. … 404 508 451 Pneumonia 373 492 272 Systolic heart failure, acute on chronic … Slide 13: Readmission Rates for Congestive Heart Failure Image: Two bar graphs show All-cause 30- … day readmission rates for congestive heart failure by age and insurance status in U.S. hospitals, 2010 … Heart Failure. COPD.

87. Final Progress Report: Risk and Recovery in Complex Environments: Labor and Delivery as a Model (pdf file)
    www.ahrq.gov/sites/default/files/2025-05/goldman2-report.pdf
    January 01, 2025 - Detailed process data relating to abnormal event sequences, non-standard operational conditions, failure … modes, failure detection, and management of adverse event sequelae relevant to our clinical focus were … If the pivotal event is an action, the success or failure of the action (e.g., provider detection of … ; and ‘what could have prevented the failure?’ … Uncertainties and quantification of common cause failure rates and probabilities for system analyses

88. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - Safety Assessment Discovery Form Safety Issues Worksheet Root Cause Analysis Learn From Defects Form Failure … from Defects The Relationship Between CUSP and Sensemaking1,2,3 Concept CUSP Sensemaking Defect or 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 … , and letter sent to manufacturer Missing equipment on cart Checklist developed for stocking cart Failure

89. 116-Cusp-Premortem-Project-Assessment (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/116-cusp-premortem-project-assessment.docx
    January 01, 2007 - Premortem Project Assessment ICU & Non-ICU 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

90. Table 7: Prevalence of selected health conditions among adults by diabetes status. All project sites. Fiscal year 2010. | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap5tab7.html
    December 01, 2017 - 1.0%     Vascular disease 9,840 3.3% 4,885 11.2% 4,955 2.0% Renal disease or failure … 8,306 2.8% 5,783 13.3% 2,523 1.0%     Renal failure 1,800 0.6% 1,449 3.3% … 618 0.2% 414 1.0% 204 0.1% CVD includes ischemic heart disease, congestive heart failure

91. Exhibit 13. Probability of intervention reducing risk of surgical site infection (SSI) by multiple concurrent interventions at various reductions of noncompliance rates (25, 5 | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh13.html
    April 01, 2018 - skin appropriately 0.0042 0.0038 0.0039 0.0040 0.0041 Gate 239 Antibiotics-related failure … skin appropriately 0.0040 0.0033 0.0035 0.0037 0.0038 Gate 239 Antibiotics-related failure … skin appropriately 0.0039 0.0027 0.0032 0.0035 0.0035 Gate 239 Antibiotics-related failure

92. Identify Defects Module Alternate Text | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/modules/identify/alt-text.html
    March 01, 2013 - 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 … CUSP uses the term "defect" while Sensemaking uses the term "failure" and further classifies failures … as (1) human/active failure or (2): latent/system conditions. 

93. Final Progress Report: A Pilot Study for Intrgrating Facility Information With Healthcare Information to Improve Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/anumba-report_0.pdf
    January 01, 2024 - Operating Room Suite Item Number Item Potential Failure Mode Failure Cause Facility Failure Effects … Health Failure effects Likelihood of Occurance Detection Method Likelihood of Detection … For each item, the “Potential Failure Modes” were listed with an associated cause and effects to the … The “Facility Failure Effects” list effects on clinical operations. … The “Health Failure Effects” list the threats to patient safety associated with the potential failure

94. NICU Family Information Packet, Appendix B, Patent Ductus Arteriosus (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-pda.pdf
    June 02, 2025 - ■ An open ductus may lead to: – Congestive heart failure. – Pulmonary hypertension. … occur within 2 months of discharge to assess well-being and the presence/absence of congestive heart failure

95. Final Progress Report: Sociotechnical Probabilistic Risk Assessment in Home Health Care (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/silver2-report.pdf
    January 01, 2025 - In this study, failure rate estimates were added to the fault tree analysis to produce a comprehensive … rates estimates, particularly for less frequently observed process failure pathways … (s) Resulting from care process failure(s) - contributing causes 15.2% 69.6% 17.4% 30.4% … The most typical form of this care process failure was a physical therapy admission of a post-surgical … A case study of operational failure in home healthcare.

96. Table 14A: Outcome Indicators by County Supply of Health Care Providers | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14.html
    February 01, 2023 - Obstructive Pulmonary Disease 3,958 3,761 4,770 3,472 3,976 3,822 Congestive Heart Failure … Obstructive Pulmonary Disease 4,158 4,050 5,076 3,660 4,262 4,001 Congestive Heart Failure … Obstructive Pulmonary Disease 3,391 2,887 3,869 2,932 3,168 3,293 Congestive Heart Failure … or Chronic Obstructive Pulmonary Disease 757 703 795 700 793 692 Congestive Heart Failure … Obstructive Pulmonary Disease 5,142 4,793 5,426 4,788 5,360 4,785 Congestive Heart Failure

97. AHRQ's RED Toolkit Helps Lower Readmissions in Dignity Health Hospitals | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/201522.html
    August 01, 2015 - ’s Medical Center, a 389-bed trauma center in Long Beach, introduced RED in December 2013 for heart failure … Mary’s Medical Center also introduced RED with heart failure patients, which helped the facility reduce … After seeing the success of the RED Toolkit in reducing readmissions among heart failure patients, officials … After seeing initial success with heart failure patients, the hospital instituted nearly all RED Toolkit

98. 0129Table8 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129table8.pdf
    January 01, 2013 - Structured telephone support or telemonitoring programmes for patients with chronic heart failure … postdischarge support for older patients with congestive heart failure: a meta-analysis. … The 10 trials assessed the effect of chronic care management programs for heart failure patients … What works in chronic care management: the case of heart failure. … Hospital strategies associated with 30-day readmission rates for patients with heart failure.

99. Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation Challenge Grant (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/jack-report.pdf
    January 01, 2024 - Words 250 Key Words: hospital discharge, re-hospitalization, process mapping, failure mode and effect … The groups then developed a potential solution for each failure mode. … Mode and Effect Analysis Potential failure mode Resultant Problem Possible Action Steps 1. … Page 18 of 19 Potential failure mode Resultant Problem Possible Action Steps 13. … mode Potential failure mode Potential failure mode

100. Financial and Demographic Influences on Medicare Patient Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
     January 01, 2004 - For failure to rescue, we considered a total of 22 complications. … For failure to rescue, the estimate is restricted to the sub-sample of major surgery discharges that … For failure to rescue and any patient death regressions, PSEiht is equal to 1 if patient i dies during … The rate of failure to rescue, the in-hospital death rate for those patients that suffer potentially … We also found that not- for-profit hospitals have a lower risk of death and failure to rescue than do