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www.healthcare411.ahrq.gov/hai/pfp/hacrate2013-appendix.html
October 01, 2015 - (2013)
Post-Op Hemorrhage or Hematoma (PSI 9)
20,000
0.61
PSI (2013)
Post-Op Respiratory Failure
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www.healthcare411.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/pa-specialinnovation.html
August 01, 2018 - Problems Addressed
Failure to identify developmental delays and autism and to intervene early can worsen
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www.healthcare411.ahrq.gov/teamstepps/readiness/index.html
August 01, 2015 - originate from a variety of sources, including adverse event and near-miss reports, root cause analyses or failure
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www.healthcare411.ahrq.gov/health-literacy/improve/precautions/guide/selfmgmt.html
September 01, 2020 - Tips for Using Survey Feedback
Don't set your practice up for failure by obtaining feedback before
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www.healthcare411.ahrq.gov/evidencenow/projects/heart-health/evidence/blood-pressure.html
March 01, 2021 - Control Evidence and Resources
High blood pressure is a major risk factor for heart attack, heart failure
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www.healthcare411.ahrq.gov/teamstepps/rrs/instructor_slides/rrsinstructmod.html
October 01, 2014 - RRSs are established to "respond to a 'spark' before it becomes a 'forest fire,'" thereby preventing failure … Failure Modes and Effects Analysis (FMEA)
This answers questions like:
What can go wrong? … Return to Top
Scenario 2
The RRT was called for a patient who had a risk of respiratory failure
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www.healthcare411.ahrq.gov/health-literacy/professional-training/lepguide/exec-summary.html
September 01, 2020 - Most were due to failure to use an appropriate interpreter. … addition, the Department of Justice and the Department of Health and Human Services have stated that failure
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0129-fullreport.pdf
December 31, 2015 - Single-component interventions effective in reducing readmissions
for patients with heart failure include … include use of a primary care medical home model (Gilfillan, et al, 2010), multidisciplinary heart
failure … peri-discharge management include comprehensive discharge
planning plus post-discharge support for heart failure … hospitals with excess readmissions following hospitalizations for acute
myocardial infarction, heart failure … hospitals
with excess readmissions following hospitalizations for acute myocardial infarction, heart failure
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www.healthcare411.ahrq.gov/teamstepps/officebasedcare/module6/office_support-ig.html
September 01, 2015 - Failure to use advocacy and assertion has been frequently identified as a primary contributor to the
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www.healthcare411.ahrq.gov/patient-safety/reports/liability/waever.html
August 01, 2017 - Strategies for learning from failure. Harvard Bus Rev 2011; 89:48–55.
31. Dekker S.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsinstructmod.ppt
January 01, 2008 - RRSs are established to “respond to a ‘spark’ before it becomes a ‘forest fire,’” thereby preventing failure … Failure Modes and Effects Analysis (FMEA)
This answers questions like:
What can go wrong? … Systems
Rapid Response Systems
SCENARIO 2
The RRT was called for a patient who had a risk of respiratory failure
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www.healthcare411.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
June 01, 2023 - Skip to main content
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
July 02, 2008 - Usually when a deep pressure injury develops, it reflects a system failure.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0134-technicalspecs.pdf
January 01, 2011 - Nephritis nephrosis, renal
sclerosis
158 2y Chronic kidney disease
157 2y Acute and unspecified
renal failure
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar05/mixed_methods.pptx
December 03, 2013 - Led by Provider A Team 5 Led by Provider B
Coronary artery disease 77% 91%
Diabetes 65% 78%
Heart Failure
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0122-fullreport.pdf
September 01, 2019 - Examples include organ failure (e.g., acute renal failure, liver, respiratory), obstetric
shock, pulmonary … one severe complication rose 75 percent over a 10-year period (from 1998-
1999 to 2008-2009): renal failure … The failure to respond urgently and definitively to fetal
distress, maternal hemorrhage, or any number … One review of maternal deaths and near misses found mismanagement of the patient
and failure or delay
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0121-fullreport.pdf
October 01, 2019 - Examples
include organ failure (e.g., acute renal failure, liver, respiratory), obstetric shock, pulmonary … prevalence of at least one severe
complication rose 75 percent from 1998-1999 to 2008-2009: renal failure … The failure to respond urgently and
definitively to fetal distress, maternal hemorrhage, or any number … One review of maternal deaths and near misses, found
mismanagement of the patient and failure or delay
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0123-fullreport.pdf
November 01, 2019 - Examples include organ failure (e.g., acute renal failure, liver, respiratory), obstetric
shock, pulmonary … one severe complication rose 75 percent over a 10-year period (from 1998-
1999 to 2008-2009): renal failure … The failure to respond urgently and definitively to fetal
distress, maternal hemorrhage, or any number … One review of maternal deaths and near misses found mismanagement of the patient
and failure or delay
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0120-fullreport.pdf
May 01, 2018 - Examples
include organ failure (e.g., acute renal failure, liver, respiratory), obstetric shock, pulmonary … of at least one severe complication of pregnancy rose 75
percent from 1998-1999 to 2008-2009: renal failure … The failure to respond
urgently and definitively to fetal distress, maternal hemorrhage or any number … One
review of maternal deaths and near misses, found mismanagement of patient, failure or delay in
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-121-technicalspecs.pdf
January 31, 2020 - Nephritis nephrosis, renal
sclerosis
158 2y Chronic kidney disease
157 2y Acute and unspecified renal
failure