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Total Results: 381 records

Showing results for "failure".

41. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
    January 01, 2024 - , and reports of preventable adverse events are increasing.2,3 Examples include fulminant hepatic failure … Moreover, because patient safety process errors such as (1) failure to institute preventive practices … failures to determine, document, or follow up on results of tests prior to medication initiation and failure … example, post-marketing surveillance data have suggested that rituximab can result in fulminant liver failure

42. Long COVID is a Case Study of Our Fractured Healthcare System | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/news/blog/ahrqviews/long-covid.html
    March 01, 2023 - Each represented a failure of our healthcare system to handle a new and growing challenge that requires … But our failure to address Long COVID has revealed severe, life-threatening gaps in care.

43. Strategies for Improving Patient Experience with Ambulatory Care: Service Recovery Programs (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-p.pdf
    November 02, 2017 - dissatisfied or lost members or patients by identifying and fixing the problem or making amends for the failure … Letting the person tell their story and describe the impact of the failure is essential. … Commit to identifying failure points in the system • Using complaint data, identify failure points

44. Specific Tools To Support Change (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/g2_combo_specifictoolstosupportchange.pdf
    January 01, 2011 - 20download/St akeholder%20analysis.do c Institute for Healthcare Improvement Analysis Tool Failure … Modes and Effects Analysis Tool Failure Modes and Effects Analysis (FMEA) is a systematic, proactive … FMEA includes review of the following: • Steps in the process • Failure modes (What could go wrong … • Failure causes (Why would the failure happen?) … • Failure effects (What would be the consequences of each failure?)

45. Data Infographics | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/data/infographics/index.html
    March 01, 2024 - 2020 Adult Opioid Fills by Race Expenditures for COVID-19 Care in 2020 Heart Failure … Disease Declining Hospital Costs for Seniors with Traditional Medicare 2020 Heart Failure

46. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
    April 01, 2021 - USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities Introduction This user guide provides step-by-step instructions for nursing home staff to use the Hand Hygien…

47. Introduction to the Quality Indicators Best Practices Tool (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
    June 05, 2016 - PSI 10 Postoperative Physiologic and Metabolic Derangement Rate • PSI 11 Postoperative Respiratory Failure … Mortality Rate • PDI 08 Perioperative Hemorrhage or Hematoma Rate • PDI 09 Postoperative Respiratory Failure

48. NPSD Dashboards | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/npsd/data/dashboard/index.html
    October 01, 2023 - 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

49. Leveraging Cultural Change to Reduce Urinary Catheter Use | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/hai/cauti-tools/archived-webinars/leveraging-cultural-change-slides.html
    December 01, 2017 - experience, history and tradition Slide 7 The Culture of Safety and Assessment of Harm Believe that failure … to follow guidelines may cause harm Built in alerts Consequences for failure to implement Slide … feeding žPressors with minimal titration žChronic Lasix žMildly sedated or drowsy Respiratory failure

50. AHRQ Pediatric Quality Indicators Prioritization Worksheet (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheet.pdf
    June 05, 2016 - Surgery Volume PDI 08 Perioperative Hemorrhage or Hematoma Rate PDI 09 Postoperative Respiratory Failure

51. Advanced Methods in Delivery System Research – Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #4: Formative Evaluation
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar04/formative_evaluation_webinar.pptx
    July 15, 2013 - views on: Usefulness or value of intervention Barriers and facilitators to implementation success or failure … refinements to implementation strategy Can provide working hypotheses on implementation success / failure

52. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/resources/learning-lab/index.html
    February 01, 2024 - Tools included process mapping, swim lane diagrams, functional resonance analysis method, failure modes … Failure to Rescue Patient Safety Learning Lab (FTR PSLL) Principal Investigator: George Blike, M.D … Failure to rescue event mitigation system assessment: a mixed-methods approach to analysis of complex … To address the specific safety failure of FTR, hospitals have introduced new tools and processes (e.g … reductions in anesthesia medication errors in operating rooms in order to address three sources of failure

53. Home Mechanical Ventilators: Protocol Appendix A (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/hmv-protocol-appendixa.pdf
    October 11, 2017 - 20526 17 *Spinal Cord Injuries/ 41566 18 *Obesity Hypoventilation Syndrome/ 991 19 *respiratory failure … Neuromuscular Disease*" or Obesity or "obstructive lung disease*" or "Pulmonary fibrosis" or "respiratory failure … Neuromuscular Disease*" or Obesity or "obstructive lung disease*" or "Pulmonary fibrosis" or "respiratory failure … Neuromuscular Disease*" or Obesity or "obstructive lung disease*" or "Pulmonary fibrosis" or "respiratory failure … Neuromuscular Disease*" or Obesity or "obstructive lung disease*" or "Pulmonary fibrosis" or "respiratory failure

54. TeamSTEPPS Fundamentals Course: Module 3. Communication | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
    March 01, 2019 - As these data illustrate, failure to communicate effectively as a team significantly increases the risk … Say: Lack of communication among department staff can lead to failure to: Sharing information with … Failure to seek input from the patient.

55. PowerPoint Presentation
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module6/6-ts-office-support.pptx
    January 20, 2006 - the patient and is invoked when team members’ viewpoints don’t coincide with that of a decisionmaker Failure … Information Ineffective Communication Conflict Time Distractions Workload Fatigue Misinterpretation of Data Failure

56. Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/research/publications/search.html
    January 01, 2024 - Successful approaches to learn from diagnostic quality and develop strategies to reduce harm from diagnostic failure

57. Slide 1
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module7/7_ts_office_summary.pptx
    January 20, 2006 - Information Ineffective Communication Conflict Time Distractions Workload Fatigue Misinterpretation of Data Failure

58. C2 Prioritization Worksheet Example (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c2_pdi_prioritizationworksheetexample.pdf
    June 05, 2016 - 0.0 4.9 0 $75,932 $ - N 6 6 6 Y Y Y Y Y PDI 09 Postoperative Respiratory Failure

59. Tool: Advocacy and Assertion | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/teamstepps-program/curriculum/mutual/tools/advocacy.html
    June 01, 2023 - Failure to use advocacy and assertion has been frequently identified as a primary contributor to the

60. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
    June 29, 2016 - Derangement 0.9 1.5 4 $120,629 $ 482,516 N 3 3 2 Y Y Y Y Y PSI 11 Postoperative Respiratory Failure … Y IQI 15 AMI Mortality 6.5 5.0 16 $38,000 $ 608,000 N 3 2 2 Y Y Y Y Y IQI 16 Heart Failure … 0.0 4.9 0 $75,932 $ - N 6 6 6 Y Y Y Y Y PDI 09 Postoperative Respiratory Failure