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Showing results for "failure".

181. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?

182. Health Information Technoloy in Heart Failure Care - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/k08hs023683-blecker-final-report-2018.pdf
     January 01, 2018 - for patients with a secondary diagnosis of heart failure. … patients are for reasons other than acute heart failure. … failure has not. … The heart failure cohort included patients hospitalized with heart failure who were discharged between … JACC Heart Failure. 2016;4:885-893. PMCID: PMC5097004. 10.

183. Failure mode and effects analysis: a useful tool for risk identification and injury prevention. | PSNet
     psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury-prevention
     September 24, 2010 - Commentary Failure mode and effects analysis: a useful tool for risk identification … Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … discusses the importance of proactive risk assessment and provides insights on the successful use of failure … Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … May 18, 2011 Failure mode and effect analysis: a technique to prevent chemotherapy errors

184. Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections. | PSNet
     psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-reduce-nicu-line-associated-bloodstream
     April 24, 2018 - Study Health care failure mode and effect analysis to reduce NICU line–associated … Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections. … Successful application of a failure mode and effect analysis approach resulted in a marked reduction … Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections. … October 13, 2010 Random safety auditing, root cause analysis, failure mode and effects

185. Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review. | PSNet
     psnet.ahrq.gov/issue/exploratory-analyses-failure-rescue-measure-evaluation-through-medical-record-review
     December 15, 2008 - Study Exploratory analyses of the "failure to rescue" measure: evaluation through … Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review. … The limitations of the failure to rescue measurement at identifying systemic problems in care delivery … Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review. … July 12, 2010 View More Related Resources Failure to rescue as

186. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. | PSNet
     psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
     July 23, 2010 - Commentary Key performance outcomes of patient safety curricula: root cause analysis, failure … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis … This commentary recommends that courses covering root cause analysis , failure mode and effects analysis … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis … See More About The Topic Pharmacists Educators Pharmacy Root Cause Analysis Failure

187. Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch health care. | PSNet
     psnet.ahrq.gov/issue/prospective-risk-analysis-health-care-processes-systematic-evaluation-use-hfmea-dutch-health
     March 10, 2010 - This study analyzed 13 failure mode and effect analysis (FMEA) efforts to understand how to improve … January 13, 2021 Application of failure mode effect analysis to improve the care of septic … June 14, 2017 Using Health Care Failure Mode and Effect Analysis: the VA National Center … March 28, 2011 Failure mode and effects analysis: an empirical comparison of failure … December 15, 2010 Using failure mode and effects analysis to plan implementation of smart

188. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867383/psn-pdf
     December 18, 2024 - Interactions between the context of a health-care organisation and failure: the situational impact of … failure on organisational learning. … failure on organisational learning. … https://psnet.ahrq.gov/issue/interactions-between-context-health-care-organisation-and-failure-situational-impact-failure … https://psnet.ahrq.gov/issue/interactions-between-context-health-care-organisation-and-failure-situational-impact-failure

189. Patient safety in complementary medicine through the application of clinical risk management in the public health system. | PSNet
     psnet.ahrq.gov/issue/patient-safety-complementary-medicine-through-application-clinical-risk-management-public
     February 15, 2023 - Failure mode and effect analysis is a process used to prospectively identify error risk within a particular … This study describes the application of failure mode and effect analysis to better understand the patient … 2020 Patient involvement in evaluation of safety in oral antineoplastic treatment: a failure … January 31, 2018 A review of healthcare failure mode and effects analysis (HFMEA) in … January 16, 2013 Using Healthcare Failure Mode and Effect Analysis to reduce medication

190. Error traps in pediatric patient blood management in the perioperative period. | PSNet
     psnet.ahrq.gov/issue/error-traps-pediatric-patient-blood-management-perioperative-period
     January 12, 2022 - This article highlights five patient safety risks during pediatric perioperative blood management (failure … to recognize and treat preoperative anemia, failure to obtain informed consent regarding perioperative … blood management, failure to consider specific intraoperative blood conservation techniques in children … , failure to recognize massive hemorrhage, failure to prevent unnecessary transfusion ).

191. Systematically Identified Failure Is the Route to a Successful Health System. | PSNet
     psnet.ahrq.gov/issue/systematically-identified-failure-route-successful-health-system
     January 10, 2018 - Special or Theme Issue Systematically Identified Failure Is the Route to a Successful … Citation Text: Systematically Identified Failure Is the Route to a Successful Health System. … Exploring challenges to system-level efforts to learn from failure in health care, articles in this … Cite Citation Citation Text: Systematically Identified Failure

192. 109-Performing-Premortem-Project-Assessment-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/109-performing-premortem-project-assessment-fg.docx
     April 01, 2025 - Slide 2 Failure in Quality Improvement Programs SAY: While not many studies have been conducted on … success or failure rates for quality improvement programs in healthcare, several articles in quality … Failure due to one or more of these reasons is possible but not inevitable. … What might cause a failure specifically for your new program? … Determine the most likely reasons for failure.

193. Situational Awareness | PSNet
     psnet.ahrq.gov/taxonomy/term/3440
     September 01, 2025 - Failure to maintain situational awareness can result in various problems that compound the crisis. … point that steps are not taken to address immediately life-threatening problems such as respiratory failure … may ignore signals from a team member, which may result in escalating anxiety for the team member, failure

194. 155-Performing-Premortem-Project-Assessment (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/155-performing-premortem-project-assessment.docx
     October 01, 2024 - Slide 2 Failure in Quality Improvement Programs SAY: While not many studies have been conducted on … success or failure rates for quality improvement programs in healthcare, several articles in quality … So, what if you could determine your team’s possible failure points before you start a new project? … What might cause a failure specifically for your new program? … Determine the most likely reasons for failure.

195. Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting. | PSNet
     psnet.ahrq.gov/issue/effect-cognitive-aids-adherence-best-practice-treatment-deteriorating-surgical-patients
     September 30, 2020 - Failure to rescue  is a significant cause of morbidity and mortality and is often associated with human … Use of cognitive aids significantly reduced omitted critical management steps and failure to adhere to … WebM&M Cases Hemorrhagic Shock after Elective Spine Surgery: Failure … January 18, 2023 Failure to rescue following emergency surgery: a FRAM analysis of the … August 20, 2018 Failure events in transition of care for surgical patients.

196. Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
     January 01, 2024 - number: P-20 HS017122-01 Final Progress Report.doc Abstract: Purpose: We performed a Healthcare Failure … Results: The HFMEA process identified 40 high-risk failure modes and 75 associated high-risk causes. … A mitigation plan was developed to address the failure modes and causes that were within the control … Healthcare Failure Mode and Effect Analysis™ (HFMEA) is one such approach to improving patient safety … in the process that was so critical that its failure would result in system failure, or an immediate

197. Device Dashboard Data 2025 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2025.xlsx
     January 01, 2025 - The tables include the relative frequencies by type of device, by device defect, failure or use error … and use error 1798 3.2% Device defect or failure, including HIT 16777 29.5% Unknown 32802 … and use error 130 13.6% No Harm Combination or interaction of device defect or failure and use … error 826 86.4% Harm Device defect or failure, including HIT 588 8.3% No Harm Device … defect or failure, including HIT 6469 91.7% Harm Unknown 718 7.2% No Harm Unknown 9223

198. FMEA team performance in health care: a qualitative analysis of team member perceptions. | PSNet
     psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member-perceptions
     December 31, 2014 - Failure mode and effect analysis (FMEA), a tool that allows prospective risk assessment, has been … December 18, 2013 Using failure mode and effects analysis to plan implementation of smart … February 19, 2020 View More Related Resources Using failure mode … June 27, 2011 Failure mode and effects analysis: an empirical comparison of failure mode … December 15, 2010 Is failure mode and effect analysis reliable?

199. Holden, Richard | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/holden-richard
     January 01, 2023 - Naturalistic decision making in everyday self-care among older adults with heart failure … Naturalistic decision making in everyday self-care among older adults with heart failure. … Self-Care Modeling personas for older adults with heart failure. … Modeling personas for older adults with heart failure. … Knowledge among patients with heart failure: A narrative synthesis of qualitative research.

200. Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management system on cancer patients' safety. | PSNet
     psnet.ahrq.gov/issue/risks-and-medication-errors-analysis-evaluate-impact-chemotherapy-compounding-workflow
     January 27, 2019 - This study applied failure mode, effect, and criticality analysis   (FMECA) methodology to identify … January 12, 2022 View More Related Resources Using failure mode … February 20, 2019 Using Failure Mode and Effects Analysis for safe administration of … May 27, 2011 Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis … March 28, 2011 Failure mode and effects analysis: an empirical comparison of failure