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Showing results for "failure".

281. 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

282. Home Heart Failure (HF) Care Comparing Patient-Driven Technology Models (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r01hs015459-goldberg-final-report-2008.pdf
     January 01, 2008 - Home Heart Failure (HF) Care Comparing Patient-Driven Technology Models Grant Final Report Grant ID … : 5R01HS015459 Home Heart Failure (HF) Care Comparing Patient-Driven Technology Models … Scope We chose this study because an estimated 4.8 million Americans have heart failure. … Heart failure is the most common diagnosis in hospital patients age 65 years and older. … Patient felt that they were doing OK with managing their heart failure 10 b.

283. 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

284. 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

285. 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

286. 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

287. PQI 10 Dehydration Admission Rate (xls file)
     qualityindicators.ahrq.gov/Downloads/ICD10/PQI%2010%20Dehydration%20Admission%20Rate.xlsx
     January 01, 2010 - with lesion of tubular necrosis N17.0 Acute kidney failure with tubular necrosis 584.6 Acute kidney … failure with lesion of renal cortical necrosis N17.1 Acute kidney failure with acute cortical necrosis … 584.7 Acute kidney failure with lesion of renal medullary [papillary] necrosis N17.2 Acute kidney failure … N17.8 Other acute kidney failure 584.9 Acute kidney failure, unspecified N17.9 Acute kidney failure … Renal failure, unspecified N19.

288. 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

289. 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

290. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40060/psn-pdf
     December 15, 2010 - Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures. … Failure Mode and Effects Analysis. J Patient Saf. 2010;6(4):210-215. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures

291. Transitions of Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html
     June 01, 2018 - Measures of transitions of care include: Hospitalized adult patients with heart failure who were … failure who were given complete written discharge instructions, by sex and race/ethnicity, 2005-2013 … Importance: Heart failure is the most frequent hospital discharge diagnosis in the older adults. … Trends: From 2005 to 2013, the percentage of hospitalized adult patients with heart failure who … For heart failure and COPD, low share is defined as ≤7% and high as ≥29%.

292. 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

293. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853244/psn-pdf
     September 06, 2023 - 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).

294. 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

295. PowerPoint Presentation: Premortem for Sustainability
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem.pptx
     December 01, 2017 - The idea is to brainstorm for possible failure points in order to address them. 3 Preparing To Lead1 … to sustain improvements Spend 10 minutes recording the reasons that could cause this failure Ask your … Use the scale shown here to rank your team’s concerns about each failure. 9 Premortem Exercise Step … ASK: What can your team implement to avoid or mitigate these failure points? … SAY: Target potential risks for failure in order to achieve success in sustainment.

296. Transitional Care Interventions To Prevent Readmissions for People With Heart Failure (pdf file)
     effectivehealthcare-admin.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

297. System failure versus personal accountability--the case for clean hands. | PSNet
     psnet.ahrq.gov/issue/system-failure-versus-personal-accountability-case-clean-hands
     February 16, 2011 - Commentary System failure versus personal accountability--the case for clean hands … System failure versus personal accountability--the case for clean hands. … System failure versus personal accountability--the case for clean hands.

298. Forgive and Remember: Managing Medical Failure. 2nd ed. | PSNet
     psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed
     March 27, 2005 - Report Classic Forgive and Remember: Managing Medical Failure … Citation Text: Forgive and Remember: Managing Medical Failure. 2nd ed. … Cite Citation Citation Text: Forgive and Remember: Managing Medical Failure … November 18, 2015 Failure in Safety-Critical Systems: A Handbook of Accident and Incident

299. 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

300. Welcome to the HCUP Nationwide Emergency Department Sample (NEDS) Overview Webinar! (pdf file)
     hcup-us.ahrq.gov/NEDSWebinarDecember2020FINAL_HCUPUS-Posted.pdf
     January 16, 2020 - heart failure I5041 Acute combined systolic (congestive) and diastolic (congestive) heart failure … chronic right heart failure I5022 Chronic systolic (congestive) heart failure I50814 Right heart failure … heart failure I5030 Unspecified diastolic (congestive) heart failure I5083 High output heart failure … (congestive) heart failure I5089 Other heart failure I5033 Acute on chronic diastolic (congestive) … heart failure I509 Heart failure, unspecified I5040 Unspecified combined systolic (congestive) and