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Showing results for "failure".

261. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
     January 01, 2023 - BOWEL PERFORATION – THE IMPORTANCE OF DIAGNOSTIC REASONING A case highlighting describing how the failure … RCA will guide this commentary with a focus on diagnostic failure, failure to identify and target early … was identified. 11 DIAGNOSTIC FAILURE 12 Diagnostic Failure (1) This patient was initially … admitted to the cardiac care unit with symptoms suggesting volume overload, presumably heart failure … Atrial fibrillation (not described here) and heart failure would put her at risk for an embolus to

262. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47584/psn-pdf
     February 20, 2019 - Patient involvement in evaluation of safety in oral antineoplastic treatment: a failure mode and effects … Patient Involvement in Evaluation of Safety in Oral Antineoplastic Treatment: A Failure Mode and Effects … https://psnet.ahrq.gov/issue/patient-involvement-evaluation-safety-oral-antineoplastic-treatment-failure … - mode-and-effects This study employed failure mode and effect analysis to detect risks in oral chemotherapy … https://psnet.ahrq.gov/issue/patient-involvement-evaluation-safety-oral-antineoplastic-treatment-failure-mode-and-effects

263. Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units. | PSNet
     psnet.ahrq.gov/issue/risk-and-pharmacoeconomic-analyses-injectable-medication-process-paediatric-and-neonatal
     December 17, 2014 - This study used failure modes and effects analysis to identify the major hazards associated with intravenous … November 29, 2023 Using Failure Mode, Effect and Criticality Analysis to improve safety … December 19, 2018 View More Related Resources Using failure mode … in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure … June 16, 2010 Random safety auditing, root cause analysis, failure mode and effects analysis

264. Premature Extubation | PSNet
     psnet.ahrq.gov/web-mm/premature-extubation
     May 25, 2011 - Only one-third of patients who required intubation were considered high risk for extubation failure by … , heart failure, or encephalopathy instead of stridor). … There is currently no consensus on optimal therapies to prevent extubation failure. … Risk factors for extubation failure in patients following a successful spontaneous breathing trial. … The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156(2 pt 1):459-465.

265. Final Topic Refinement Document: Home Mechanical Ventilators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
     October 01, 2017 - the home through a noninvasive interface for the population of patients with chronic respiratory failure … Draft analytic framework for home mechanical ventilators Background Chronic respiratory failure … Many disease conditions may contribute to chronic respiratory failure including, but not limited to … Mechanical ventilation is used to treat chronic respiratory failure. … There is considerable variability regarding the continuum of severity of chronic respiratory failure.

266. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867340/psn-pdf
     December 11, 2024 - Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative … Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative … https://psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion … https://psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion-safety-incidents … https://psnet.ahrq.gov/issue/multiple-points-system-failure-underpin-continuous-subcutaneous-infusion-safety-incidents

267. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72856/psn-pdf
     March 17, 2021 - The fusion of incident learning and failure mode and effects analysis for data-driven patient safety … The fusion of incident learning and failure mode and effects analysis for data-driven patient safety … https://psnet.ahrq.gov/issue/fusion-incident-learning-and-failure-mode-and-effects-analysis-data-driven … authors propose a method which leverages a radiation oncology incident learning system with a simplified failure … https://psnet.ahrq.gov/issue/fusion-incident-learning-and-failure-mode-and-effects-analysis-data-driven-patient-safety

268. Tool: Premortem (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/premortem-tool.docx
     January 01, 2017 - The team then develops plans to mitigate these reasons for failure. … · “Spend the next 10 minutes writing down all the reasons you believe this failure occurred. … The team will then develop plans to mitigate these reasons for failure. … Please spend the next 10 minutes writing down all the reasons you believe this failure occurred. … REASONS FOR FAILURE What could have caused this?

269. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72682/psn-pdf
     January 27, 2021 - Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection … Healthcare Failure Mode and Effect Analysis (HFMEA) as an Effective Mechanism in Preventing Infection … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism- … This article describes the use of healthcare failure mode and effects analysis (HFMEA) 4- step model … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism-preventing-infection

270. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/844769/psn-pdf
     January 01, 2020 - Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot … Failure to administer recommended chemotherapy: acceptable variation or cancer care quality blind spot … https://psnet.ahrq.gov/issue/failure-administer-recommended-chemotherapy-acceptable-variation-or- cancer-care-quality-blind … The authors conclude that failure to administer chemotherapy is a significant safety gap that should … https://psnet.ahrq.gov/issue/failure-administer-recommended-chemotherapy-acceptable-variation-or-cancer-care-quality-blind

271. Early Mobility in the Intensive Care Unit: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-slides.html
     February 01, 2017 - Early activity is feasible and safe in respiratory failure patients. … Early activity is feasible and safe in respiratory failure patients. … Early activity is feasible and safe in respiratory failure patients. … Early activity is feasible and safe in respiratory failure patients. … Early activity is feasible and safe in respiratory failure patients.

272. Goldberg, Lee | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/goldberg-lee
     January 01, 2023 - Principal Investigator Goldberg, Lee Project Name Home Heart Failure (HF) Care: Comparing … Principal Investigator Goldberg, Lee Project Name Home Heart Failure (HF) Care: Comparing … Models - 2008 Principal Investigator Goldberg, Lee Project Name Home Heart Failure … (HF) Care: Comparing Patient-Driven Technology Models Home Heart Failure (HF … impact of health IT on clinical and financial outcomes for patients with symptomatic congestive heart failure

273. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866517/psn-pdf
     August 14, 2024 - Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. … Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. … https://psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and- … https://psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced … https://psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced

274. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46807/psn-pdf
     July 02, 2019 - Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions … Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions … https://psnet.ahrq.gov/issue/communication-failure-analysis-prescribers-use-internal-free-text-field- … More than 10% of medication orders exhibited a communication failure between prescriber and pharmacist … https://psnet.ahrq.gov/issue/communication-failure-analysis-prescribers-use-internal-free-text-field-electronic

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73241/psn-pdf
     May 12, 2021 - Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic … Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic … https://psnet.ahrq.gov/issue/delayed-or-failure-follow-abnormal-breast-cancer-screening-mammograms- … https://psnet.ahrq.gov/issue/delayed-or-failure-follow-abnormal-breast-cancer-screening-mammograms-primary-care-systematic … https://psnet.ahrq.gov/issue/delayed-or-failure-follow-abnormal-breast-cancer-screening-mammograms-primary-care-systematic

276. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/865308
     January 01, 2024 - impact of failure on organisational learning. … foundational-science-learning-health-systems 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 … situational impact of failure on organisational learning. … https://psnet.ahrq.gov/issue/interactions-between-context-health-care-organisation-and-failure-situational-impact-failure

277. The Basics of FMEA. 2nd ed. | PSNet
     psnet.ahrq.gov/issue/basics-fmea-2nd-edition
     October 23, 2013 - The authors provide a handbook that serves as the core tool for understanding and implementing the failure … to be used by technical and administrative employees at all levels to learn about opportunities for failure … November 21, 2016 Failure mode and effects analysis: a comparison of two common risk … May 4, 2016 Strategies and tips for maximizing failure mode and effect analysis in your … See More About The Topic Health Care Providers Non-Health Care Professionals Failure

278. Improving the accuracy of patient identification in the medication-use process. | PSNet
     psnet.ahrq.gov/issue/improving-accuracy-patient-identification-medication-use-process
     May 09, 2014 - Investigators from a tertiary care academic medical center describe a failure mode and effects analysis … August 31, 2022 Algorithmic prediction of failure modes in healthcare. … January 22, 2017 A proactive risk avoidance system using failure mode and effects analysis … November 1, 2010 Is failure mode and effect analysis reliable? … The Topic General Hospitals Quality and Safety Professionals Identification Errors Failure

279. 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

280. Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-woods_79.pdf
     May 30, 2008 - Failure events in Risk Bins I and II become the focus for targeted attention. … of failure mode CP3 Significant Significant impact on the chance of failure mode CP4 Certain Almost … In this study, these groups are called “failure categories.” … Representative cases are then selected from the failure categories. … Failure modes and effects analysis in healthcare.