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www.healthcare411.ahrq.gov/patient-safety/settings/hospital/resource/qitool/index.html
March 01, 2017 - Hemorrhage PDF [76.1 KB] PSI10 Postoperative Derangement PDF [86 KB] PSI11 Postoperative Respiratory Failure … Surgery PDF [74.18 KB] PDI08 Perioperative Hemorrhage PDF [81 KB] PDI09 Postoperative Respiratory Failure
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www.healthcare411.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar04/formativeevalsl.html
January 01, 2014 - Barriers and facilitators to implementation success or failure. … Can provide working hypotheses on implementation success / failure.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
July 14, 2023 - related to financial payouts; up to one-
third of all cases that end in a claim have a diagnostic failure
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
June 01, 2014 - PSI Post-Op Hemorrhage
or Hematoma (PSI 9)
21,000 0.63 20,000 0.60
PSI Post-Op Respiratory
Failure
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www.healthcare411.ahrq.gov/talkingquality/translate/organize/index.html
March 01, 2016 - , effectiveness, timeliness)
Organizing Measures by Disease or Condition (e.g., congestive heart failure
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/Lion-Mangione-Britto.pdf
October 01, 2011 - The most common rea-
sons for exclusion were failure to specifically mention IPC use,
failure to evaluate … 5 randomized controlled trial; COPD 5 chronic obstructive pulmonary disease; CHF 5 congestive heart failure … to be taken,
CHD, hyper- within a medical home model
tension, heart clinic; controls were drawn
failure … 5 randomized controlled trial; COPD 5 chronic obstructive pulmonary disease; CHF 5 congestive heart failure … randomized controlled trial; COPD 5 chronic obstructive pulmonary disease; CHF 5
congestive heart failure
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www.healthcare411.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumkhar.html
October 01, 2014 - Assess quality management characteristics by conducting a Failure Mode Effects and Criticality Analysis
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www.healthcare411.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumpete.html
October 01, 2014 - Peterson's long-term career goal is to improve outcomes for patients with heart failure through comparative
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-233-fullreport.pdf
August 07, 2018 - pregnancies is a broad topic, teratogen use in pregnancy offers a window that addresses a
potential failure … endorsed the importance of preconception care and the use of
exposure to teratogens as a marker of failure … The current measure focuses
on teratogenic drug exposure as a marker of failure of availability of services … PQMP measure set on availability of
preconception HROB services, we use teratogen use as a marker of failure … At the individual level, the use of teratogens during pregnancy represents a
failure of patient safety
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www.healthcare411.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - It is important to reinforce what went well and avoid assigning blame or failure to any individual regarding
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www.healthcare411.ahrq.gov/cahps/cahps-database/hp-database/participate.html
December 01, 2023 - Failure to follow these guidelines will result in your data not being included in the database.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-probabilistic-thinking.pdf
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.”
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module9.pptx
March 07, 2019 - minutes to think of a story related to organizational change
What things were critical to the success or failure … Once you have identified an event, think about things that were critical to either the success or failure … Failure in implementing change is often due to under-communication. … Failure to implement change is often the result of undercommunicating or communicating poorly the plan
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www.healthcare411.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html
January 01, 2020 - evidence for implementation when people are engaged in making something work rather than focused on the "failure … Psychological barriers such as fear of change, fear of failure, grief over loss of familiar processes … for two of the fundamental barriers to change: the fear of new ways of doing things and the fear of failure
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www.healthcare411.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
April 01, 2018 - Training
0
619
Error Reporting and Analysis
206
625
-- Error Analysis
185
627
---- Failure
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
November 01, 2012 - Postoperative respiratory failure is not currently part of Medicare’s Hospital Value-Based
Purchasing … Also consider performing a failure mode and effects analysis to better understand
the process and where
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-12-intro-to-assessing-practices.pdf
September 01, 2015 - Clinical performance • Key performance and outcome metrics for:
o Coronary artery disease (CAD)
o Heart failure … fall-out” assessments, where a forensic
analysis of system “failures” identifies the reasons for the failure
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-232-fullreport.pdf
June 01, 2018 - Sepsis is a potentially catastrophic condition that can escalate from infection to organ failure and … goal-directed, stepwise
procedures to hinder or reverse the cascade of events in sepsis that lead to organ failure … defects in oxygen delivery,
7
culminating in failure of vital organs (Dünser, Festic, Dondorp, … The process, however, ultimately leads to tissue damage and organ failure. … appropriate antibiotics), as well as suboptimal resuscitation, contribute to peripheral vascular
failure
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2023.pdf
March 01, 2024 - related to financial payouts; up to one-
third of all cases that end in a claim have a diagnostic failure
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1c_combo_pdifactsheet.pdf
October 01, 2015 - 0340 2012
PDI 08 Perioperative Hemorrhage or Hematoma Rate 5.2
PDI 09 Postoperative Respiratory Failure