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Showing results for "failure".

  1. Sensemakingnotes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
    June 02, 2025 - The Failure Mode and Effects Analysis tool provides a way to conduct a step-by-step analysis staff can … A failure mode and effects analysis is different from a root cause analysis, in that the failure mode … It looks at human failure, technical failure, and organizational failure. … the failure. … On this worksheet, you see both a failure and a recovery side.

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74084/psn-pdf
    November 17, 2021 - Healthcare failure mode and effect analysis in the chemotherapy preparation process. … Healthcare failure mode and effect analysis in the chemotherapy preparation process. … Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and … Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile … Potential approaches to reduce these failure modes include updating the Standard Operating Procedures

  3. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet

    psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - Sinigayan, MD, and Mithu Molla, MD, MBA This is an unfortunate case describing the failure to identify … RCA will guide this commentary with a focus on diagnostic failure, failure to identify and target early … volume overload, presumably heart failure, and this initial diagnosis likely had a powerful impact on … the failure to consider alternative diagnoses. … There was failure in the fourth step in the diagnostic process, verifying the diagnosis by ruling out

  4. Taxonomic Guidance for Remedial Actions (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
    December 23, 2004 - The three main categories are mistaken action, failure of detection, and failure of reaction. … Level 3: What contributed to the failure? … In theory, the remedial action required to address a given failure not only depends on what that failure … The row labels are a sampling of the failure classification in the taxonomy. … manifested itself, and the causes of the failure on two levels.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73608/psn-pdf
    January 01, 2022 - Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure … Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure … involving pharmacists to reduce polypharmacy and inappropriate medications for patients with heart failure … successful when specific guidelines or recommendations to assess appropriate prescribing of heart failure … effect-pharmacist-counseling-intervention-health-care-utilization-following-hospital https://psnet.ahrq.gov/issue/prescribing-patterns-heart-failure-exacerbating-medications-following-heart-failure

  6. Making FMEA work for you. | PSNet

    psnet.ahrq.gov/issue/making-fmea-work-you
    July 01, 2019 - This commentary describes failure mode and effects analysis and discusses how it can improve patient … May 28, 2014 Failure mode and effects analysis: a useful tool for risk identification … October 3, 2011 Failure mode and effect analysis: a technique to prevent chemotherapy … About The Topic Nurses Nurse Managers Quality and Safety Professionals Nurse Care Failure

  7. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency … Acute decompensated heart failure update. Curr Cardiol Rev. 2015;11(1):53-62. … Role of high-dose intravenous nitrates in hypertensive acute heart failure.  … Trial in Congestive Heart Failure (MERIT-HF). … The Role of the Clinical Examination in Patients With Heart Failure.

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845637/psn-pdf
    March 08, 2023 - Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription … Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription … https://psnet.ahrq.gov/issue/using-failure-mode-effect-and-criticality-analysis-improve-safety-cancer … - treatment Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying … health medical residents calculated a Risk Priority Number (RPN), or criticality, for each possible failure

  9. 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.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74053/psn-pdf
    November 10, 2021 - Prevention of failure to rescue in obstetric patients: a realist review. … Prevention of failure to rescue in obstetric patients: a realist review. … https://psnet.ahrq.gov/issue/prevention-failure-rescue-obstetric-patients-realist-review Failure to … https://psnet.ahrq.gov/issue/prevention-failure-rescue-obstetric-patients-realist-review https://psnet.ahrq.gov … /primer/failure-rescue https://psnet.ahrq.gov/web-mm/failure-rescue-mother https://psnet.ahrq.gov/issue

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72696/psn-pdf
    February 03, 2021 - Exploring the association between organizational safety climate, failure to rescue, and mortality in … Exploring the Association Between Organizational Safety Climate, Failure to Rescue, and Mortality in … https://psnet.ahrq.gov/issue/exploring-association-between-organizational-safety-climate-failure-rescue … - and-mortality Lack of communication and interpersonal dynamics can contribute to failure to rescue … safety climate, but the authors did not find an association between organizational safety culture and failure

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845277/psn-pdf
    March 01, 2023 - Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality … Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality … https://psnet.ahrq.gov/issue/risk-assessment-acute-stroke-diagnostic-process-using-failure-modes-effects … to screen patients for stroke soon after presentation to the Emergency Department (ED), failure to … obtain an accurate history, and failure to consider a stroke diagnosis during triage.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73371/psn-pdf
    June 09, 2021 - Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … https://psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect … - analysis-combined Failure mode and effect analysis (FMEA) is widely used to identify latent safety … The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with

  14. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
    January 01, 2024 - to report 20 Performance – delay or failure to obtain specimen 4 Ordering – delay or failure to order … or failure to report results 5 Performance – wrong study performed 3 (1) Ordering – delay or failure … For each of the process steps, failure modes were determined. … Once the failure modes were determined, the hazard analysis was conducted. … The question measures the likelihood of detecting failure or the effect of the failure before it occurs

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865817/psn-pdf
    May 08, 2024 - Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in … Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in … https://psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-prospective-medication … In this study, a hospital used Healthcare Failure Mode and Effect Analysis (HFMEA) to prospectively … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use https://psnet.ahrq.gov

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854992/psn-pdf
    November 01, 2023 - Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? … Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? … https://psnet.ahrq.gov/issue/failure-rescue-patient-safety-indicator-neurosurgical-patients-are-we-there-yet … Failure to rescue (FTR) quality metrics measure the ability of healthcare teams and hospitals to prevent … https://psnet.ahrq.gov/primer/failure-rescue https://psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72632/psn-pdf
    January 13, 2021 - Algorithmic prediction of failure modes in healthcare. … Algorithmic prediction of failure modes in healthcare. … https://psnet.ahrq.gov/issue/algorithmic-prediction-failure-modes-healthcare Failure mode and effect … This study found that an algorithmic prediction of failure modes in healthcare (APFMH) is more effective … https://psnet.ahrq.gov/issue/algorithmic-prediction-failure-modes-healthcare https://psnet.ahrq.gov/issue

  18. Part 2: Trends in Priorities of the Heckler Report—Care for Cardiovascular Diseases | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part2-cvd.html
    May 01, 2018 - Same Narrowing Hospital patients with heart failure and left ventricular systolic dysfunction … Hispanics and Whites had similar rates of admission for congestive heart failure. … Importance: Early detection and treatment of high blood pressure can prevent heart failure, kidney failure … Admissions for Congestive Heart Failure Adult admissions for congestive heart failure per 100,000 population … Importance: Racial disparities in care for congestive heart failure have been observed.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48162/psn-pdf
    July 24, 2019 - Allowing failure for educational purposes in postgraduate clinical training: a narrative review. … Allowing failure for educational purposes in postgraduate clinical training: A narrative review. … https://psnet.ahrq.gov/issue/allowing-failure-educational-purposes-postgraduate-clinical-training-narrative … - review Learning from failure is more appropriate in some contexts than others. … https://psnet.ahrq.gov/issue/allowing-failure-educational-purposes-postgraduate-clinical-training-narrative-review

  20. Comparative Effectiveness of β-Adrenergic Antagonists on the Risk of Rehospitalization in Adults with Heart Failure (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/heart-failure-rehospitalization_research.pdf
    November 01, 2007 - therapies or adverse outcomes in persons with heart failure. … Effect of carvedilol on survival in severe chronic heart failure. … Xamoterol in severe heart failure. The Xamoterol in Severe Heart Failure Study Group. … FAILURE 4280 CHF NOS 4281 LEFT HEART FAILURE 4282 … SYSTOLIC HEART FAILURE 4283 DIASTOLIC HEART FAILURE 4284 SYSTOLIC & DIASTOLIC HF
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