-
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
-
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
-
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
-
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
-
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
-
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
-
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.
-
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.
-
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
-
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
-
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
-
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
-
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
-
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
-
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.
-
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.
-
www.ahrq.gov/npsd/data/dashboard/devices.html
September 01, 2025 - dashboard details the type of device; type of device by residual harm to the patient; device defect, failure … , or user error; device defect, failure, or user error by residual harm to the patient; type of health
-
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
-
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
-
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