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Showing results for "failure".

301. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47502/psn-pdf
     June 02, 2019 - Failure to debrief after critical events in anesthesia is associated with failures in communication … Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication … https://psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures- communication-during … https://psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures-communication-during … https://psnet.ahrq.gov/issue/failure-debrief-after-critical-events-anesthesia-associated-failures-communication-during

302. St. Vincent Healthcare | Digital Healthcare Research
     digital.ahrq.gov/organization/st-vincent-healthcare
     January 01, 2023 - Vincent Healthcare Home Heart Failure (HF) Care: Comparing Patient-Driven … 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

303. Variation in hospital mortality associated with inpatient surgery. | PSNet
     psnet.ahrq.gov/issue/variation-hospital-mortality-associated-inpatient-surgery
     August 02, 2015 - Surgical Quality Improvement Program to examine whether mortality after surgery was also influenced by " failure … to rescue "—failure to recognize and treat complications.  … August 20, 2018 Importance of teamwork, communication and culture on failure-to-rescue … September 24, 2017 Interpersonal and organizational dynamics are key drivers of failure … October 14, 2020 Failure events in transition of care for surgical patients.

304. Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary | PSNet
     psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
     February 26, 2025 - ) technique to analyze numerous patient safety reports, aggregate proactive risk assessments (e.g., Failure … with main process steps and sub-steps depicting how the flow of outpatient blood draws and revealing failure … The flow diagram summarizes the process and reveals a list of all failure modes. … Approximately one-third of failure modes ( n =14) were identified by at least one facility, and about … three-quarters of failure modes ( n =32) were not analyzed by any of the 3 facilities in the proactive

305. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     May 01, 2017 - Sensemaking tools include— • Discovery Form • Root Cause Analysis • Failure Mode and Effects Analysis … • A rule-based failure occurs when a person does not carry out a procedure or protocol correctly or … Sensemaking calls for teams to collaboratively seek a solution to the failure identified on their L … the failure. … On this worksheet, you see both a failure and a recovery side.

306. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47583/psn-pdf
     December 05, 2018 - Interpersonal and organizational dynamics are key drivers of failure to rescue. … Interpersonal And Organizational Dynamics Are Key Drivers Of Failure To Rescue. … https://psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue … Stakeholders at five Michigan hospitals identified two changeable causes of failure to rescue: delayed … https://psnet.ahrq.gov/issue/interpersonal-and-organizational-dynamics-are-key-drivers-failure-rescue

307. Facilitator Guide: Sustainability and the Premortem (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem_facnotes.docx
     December 01, 2017 - allows teams to reflect on how the project might fail before it starts and build in practices to prevent failure … The idea is to brainstorm for possible failure points in order to address them. … Use the scale shown here to rank your team’s concerns about each failure. … 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.

308. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44756/psn-pdf
     September 12, 2016 - Importance of teamwork, communication and culture on failure-to-rescue in the elderly. … Importance of teamwork, communication and culture on failure-to-rescue in the elderly. … https://psnet.ahrq.gov/issue/importance-teamwork-communication-and-culture-failure-rescue-elderly Failure-to-rescue … The authors suggest that teamwork and communication improvement can help reduce failure-to-rescue in … https://psnet.ahrq.gov/issue/importance-teamwork-communication-and-culture-failure-rescue-elderly https

309. Table 1 (pdf file)
     hcup-us.ahrq.gov/toolssoftware/comorbidityicd10/TableofChanges2018_1.pdf
     January 01, 2018 - without myopathy ARTH M3393 Dermatopolymyositis, unspecified without myopathy ARTH I50810 Right heart failure … , unspecified CHF I50811 Acute right heart failure CHF I50812 Chronic right heart failure CHF I50813 … Acute on chronic right heart failure CHF I50814 Right heart failure due to left heart failure CHF … I5082 Biventricular heart failure CHF I5083 High output heart failure CHF I5084 End stage heart … failure CHF I5089 Other heart failure CHF E1110 Type 2 diabetes mellitus with ketoacidosis without

310. Automation failures and patient safety. | PSNet
     psnet.ahrq.gov/issue/automation-failures-and-patient-safety
     November 21, 2012 - Review Automation failures and patient safety. Citation Text: Ruskin KJ, Ruskin AC, O’Connor M. Automation failures and patient safety. Curr Opin Anaesthesiol. 2020;33(6):788-792. doi:10.1097/aco.0000000000000935. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 X…

311. Deconstructing intraoperative communication failures. | PSNet
     psnet.ahrq.gov/issue/deconstructing-intraoperative-communication-failures
     July 25, 2012 - Study Deconstructing intraoperative communication failures. Citation Text: Hu Y-Y, Arriaga AF, Peyre S, et al. Deconstructing intraoperative communication failures. J Surg Res. 2012;177(1):37-42. doi:10.1016/j.jss.2012.04.029. Copy Citation Format: DOI Google Scholar PubM…

312. Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. | PSNet
     psnet.ahrq.gov/issue/escalation-care-surgery-systematic-risk-assessment-prevent-avoidable-harm-hospitalized
     December 17, 2014 - Delays in this process can lead to critical failure-to-rescue events, which may result in preventable … This study used ethnographic observations, a risk assessment survey, and a formal health care failure … September 9, 2015 A systematic review to identify the factors that affect failure to … September 12, 2016 Escalation of care and failure to rescue: a multicenter, multiprofessional … September 10, 2014 Augmenting health care failure modes and effects analysis with simulation

313. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838022/psn-pdf
     September 07, 2022 - Organisational failure: rethinking whistleblowing for tomorrow's doctors. … Organisational failure: rethinking whistleblowing for tomorrow’s doctors. … https://psnet.ahrq.gov/issue/organisational-failure-rethinking-whistleblowing-tomorrows-doctors Normalization … https://psnet.ahrq.gov/issue/organisational-failure-rethinking-whistleblowing-tomorrows-doctors https

314. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838175/psn-pdf
     September 28, 2022 - Modes of failure in venous thromboembolism prophylaxis. … Modes of failure in venous thromboembolism prophylaxis. … https://psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis Hospital-acquired venous … https://psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis https://psnet.ahrq.gov/

315. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35721/psn-pdf
     March 28, 2011 - Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis … - pediatric The authors applied the VA's Health Care Failure Mode and Effect Analysis (HFMEA) process … to vincristine  errors and found the tool to be effective in identifying failure.

316. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/867659
     July 10, 2024 - piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure … Web M&Ms Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to … https://psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing … All Library Content Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited … piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure

317. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/identify/notes.html
     December 01, 2012 - 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.

318. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48093/psn-pdf
     July 24, 2019 - Failure to report poor care as a breach of moral and professional expectation. … Failure to report poor care as a breach of moral and professional expectation. … https://psnet.ahrq.gov/issue/failure-report-poor-care-breach-moral-and-professional-expectation Culture … https://psnet.ahrq.gov/issue/failure-report-poor-care-breach-moral-and-professional-expectation https

319. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45827/psn-pdf
     January 24, 2018 - Using failure mode and effects analysis to reduce patient safety risks related to the dispensing process … Using Failure mode and Effects Analysis to reduce patient safety risks related to the dispensing process … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-reduce-patient-safety-risks-related … - dispensing Failure mode and effect analysis is a tool commonly used to proactively assess the reliability … The authors describe the application of failure mode and effect analysis to identify failure modes in

320. 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.