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psnet.ahrq.gov/node/38879/psn-pdf
March 02, 2011 - The competent surgeon: individual accountability in the
era of "systems" failure. … The competent surgeon: individual accountability in the era of "systems" failure. … https://psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
Discussing … https://psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
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qualityindicators.ahrq.gov/Downloads/Resources/Presentations/2005/2005AHRQQI_Romano_Selecting_Quality_Measures.ppt
January 01, 2005 - 14,055 ± 1060 1.091
Postoperative thromboembolism 75,811 ± 4,156 0.919
Postoperative respiratory failure … to rescue
(44% change 2 deciles) Postoperative respiratory
failure (11%) Postop abdominopelvic
wound … to rescue
Anesth complications
Postop resp failure
Postop sepsis
Postop DVT/PE
Death low mort DRGs
Ob … to rescue
Postop hemorrhage
Complic anesth
Postop hip frx
Postop physio derange
Postop resp failure … to rescue
Anesth complications
Postop resp failure
Postop sepsis
Postop DVT/PE
Death low mort DRGs
Ob
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psnet.ahrq.gov/node/43363/psn-pdf
September 12, 2016 - Escalation of care and failure to rescue: a multicenter,
multiprofessional qualitative study. … Escalation of care and failure to rescue: a multicenter,
multiprofessional qualitative study. … https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative … https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study … https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study
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psnet.ahrq.gov/node/45710/psn-pdf
December 22, 2017 - Our current approach to root cause analysis: is it
contributing to our failure to improve patient safety … Our current approach to root cause analysis: is it contributing to our
failure to improve patient safety … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety
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psnet.ahrq.gov/node/39542/psn-pdf
May 19, 2010 - Random safety auditing, root cause analysis, failure mode
and effects analysis. … Random Safety Auditing, Root Cause Analysis, Failure Mode and Effects Analysis. … https://psnet.ahrq.gov/issue/random-safety-auditing-root-cause-analysis-failure-mode-and-effects-analysis … https://psnet.ahrq.gov/issue/random-safety-auditing-root-cause-analysis-failure-mode-and-effects-analysis
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psnet.ahrq.gov/node/36911/psn-pdf
September 01, 2011 - Managing clinical failure: a complex adaptive system
perspective. … Managing clinical failure: a complex adaptive system perspective. … https://psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
The investigators … https://psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - Why focus on postoperative respiratory failure in children? … Generally, postoperative respiratory
failure is the failure to wean from mechanical ventilation within … Why focus on postoperative respiratory failure? [PowerPoint]. … Consultation with the specialist: respiratory failure in children. … Why focus on postoperative respiratory failure in children?