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Showing results for "failure".

221. Table 4. Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-section-6-table-4.pdf
     April 30, 2018 - 3 100% 1.00 Having congestive heart failure 3 100% 1.00 Severe sepsis 7 86% 0.72 Septic shock … 7 86% 0.70 Hospital #2 Timely fluid bolus 3 67% 0.00 In the NICU 4 100% 1.00 Having renal failure … 3 100% 1.00 Having congestive heart failure 3 100% 1.00 Severe sepsis 4 75% 0.00 Septic shock … 4 75% 0.00 Hospital #3 Timely fluid bolus 4 75% 0.50 In the NICU 4 100% 1.00 Having renal failure … 4 100% 1.00 Having congestive heart failure 4 100% 1.00 Severe sepsis 4 100% 1.00 Septic shock

222. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
     April 07, 2008 - add new failure modes), and revised the list of failure modes accordingly. … The FMEA team also categorized each failure mode as either an active failure or a latent condition.1 … Failure modes and effects analysis with risk priority number Failure mode (What could/does go wrong … ) Type of failure Effect (Outcome from failure) L S D RPN Lack of identified role for all team … Results of root cause analysis Rank Failure mode (What could/does go wrong) Type of failure

223. 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

224. Protocol - Use of Cardiac Resynchronization Therapy: A Systematic Review Update (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/crt-update_protocol.pdf
     January 10, 2019 - but also the prevention of clinical deterioration in patients with mild heart failure. … failure patients, patients with heart failure, and cardiac implantable electronic device manufacturers … Cardiac-resynchronization therapy for mild-to-moderate heart failure. … Cardiac-resynchronization therapy for the prevention of heart-failure events. … [mh] OR "heart failure"[tiab] OR "Cardiac Failure" [tiab] OR "Myocardial Failure" [tiab] OR “Cardiac

225. Learning from failure: the need for independent safety investigation in healthcare. | PSNet
     psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare
     September 24, 2018 - Commentary Learning from failure: the need for independent safety investigation in … Learning from failure: the need for independent safety investigation in healthcare. … Learning from failure: the need for independent safety investigation in healthcare.

226. The competent surgeon: individual accountability in the era of "systems" failure. | PSNet
     psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
     May 30, 2014 - Commentary The competent surgeon: individual accountability in the era of "systems" failure … The competent surgeon: individual accountability in the era of "systems" failure. … The competent surgeon: individual accountability in the era of "systems" failure.

227. 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.

228. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50884/psn-pdf
     February 12, 2020 - Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization … Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization … - failure Various potentially inappropriately prescribed medications can exacerbate heart failure ( … https://psnet.ahrq.gov/issue/prescribing-patterns-heart-failure-exacerbating-medications-following-heart-failure … https://psnet.ahrq.gov/issue/prescribing-patterns-heart-failure-exacerbating-medications-following-heart-failure

229. MEDICAL MANAGEMENT OF CONGESTIVE HEART FAILURE AND THE EFFECTIVENESS OF ISOSORBIDE DINITRATE AND HYDRALAZINE (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/pdf/congestive-heart-failure-medicines_research.pdf
     March 01, 2010 - MEDICAL MANAGEMENT OF CONGESTIVE HEART FAILURE AND THE EFFECTIVENESS OF ISOSORBIDE DINITRATE AND HYDRALAZINE … hospitalization in veterans with heart failure. … Effect of vasodilator therapy on mortality in chronic congestive heart failure. … Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. … Clinical Performance Measures) Endorsed by the Heart Failure Society of America.

230. Blecker, Saul B. | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/blecker-saul-b
     January 01, 2023 - Project Name Health Information Technology in Heart Failure Care Effect of … Technology in Heart Failure Care - Final Report Citation Blecker S. … Health Information Technology in Heart Failure Care - Final Report. … of patients with acute decompensated heart failure. … Early identification of patients with acute decompensated heart failure.

231. Transitional Care Interventions To Prevent Readmissions for People With Heart Failure (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/pdf/heart-failure-transition-care_policymaker.pdf
     August 01, 2016 - Transitional Care Interventions To Prevent Readmissions for People With Heart Failure B A C K G R O … U N D Heart failure (HF) is a major clinical and public health problem and a leading cause of hospitalization … Transitional Care Interventions To Prevent Readmissions for People With Heart Failure K E Y I S S … CD-ROM = compact disc read-only memory; HF = heart failure AHRQ Pub. … http://www.effectivehealthcare.ahrq.gov/heart-failure http://www.ahrq.gov

232. Failure to weigh patients in hospital: a medication safety risk. | PSNet
     psnet.ahrq.gov/issue/failure-weigh-patients-hospital-medication-safety-risk
     April 22, 2015 - Study Failure to weigh patients in hospital: a medication safety risk. … Failure to weigh patients in hospital: a medication safety risk. Intern Med J. 2007;37(9):647-50. … Failure to weigh patients in hospital: a medication safety risk.

233. Managing clinical failure: a complex adaptive system perspective. | PSNet
     psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
     August 13, 2014 - Study Managing clinical failure: a complex adaptive system perspective. … Managing clinical failure: a complex adaptive system perspective. … Managing clinical failure: a complex adaptive system perspective.

234. 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?

235. EHC Protocol: Making Healthcare Safer IV: Failure to Rescue: Rapid Response Systems (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs4-failure-rescue-protocol_0.pdf
     July 01, 2023 - EHC Protocol: Making Healthcare Safer IV: Failure to Rescue: Rapid Response Systems 1 Evidence-based … Practice Center Rapid Review Protocol Project Title: Making Healthcare Safer IV: Failure to Rescue … What is the frequency and severity of harms associated with the failure to rescue that is targeted … What patient safety measures or indicators have been used to examine the harms associated with this failure … ) or response (i.e., efferent limb failure).15, 19-21 Overview of the PSP Rapid response systems

236. 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

237. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867633/psn-pdf
     February 26, 2025 - Failure to rescue female patients undergoing high-risk surgery. … Failure to rescue female patients undergoing high-risk surgery. … https://psnet.ahrq.gov/issue/failure-rescue-female-patients-undergoing-high-risk-surgery Failure-to-rescue … https://psnet.ahrq.gov/issue/failure-rescue-female-patients-undergoing-high-risk-surgery https://psnet.ahrq.gov … /primer/failure-rescue https://psnet.ahrq.gov/web-mm/failure-rescue-mother

238. 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.

239. 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.

240. Untold Stories in User-centered design of mobile health: practical challenges and strategies learned from the design and evaluation of an app for older adults with heart failure. | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
     digital.ahrq.gov/ahrq-funded-projects/power-patient-design-and-test-closed-loop-interactive-it-geriatric-heart/citation/untold
     January 01, 2020 - challenges and strategies learned from the design and evaluation of an app for older adults with heart failure … challenges and strategies learned from the design and evaluation of an app for older adults with heart failure … Project Name:  Power to the Patient: Design and Test of Closed-Loop Interactive IT for Geriatric Heart Failure … App Population:  Elderly , Individuals with Chronic Care Needs Medical Condition:  Congestive Heart Failure