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Showing results for "failure".

  1. Cutting-edge efforts in surgical patient safety. | PSNet

    psnet.ahrq.gov/issue/cutting-edge-efforts-surgical-patient-safety
    August 02, 2015 - August 2, 2015 Interpersonal and organizational dynamics are key drivers of failure to … June 18, 2019 Rapid response teams as a patient safety practice for failure to rescue … June 14, 2017 Importance of teamwork, communication and culture on failure-to-rescue … September 12, 2016 Failure to rescue following emergency surgery: a FRAM analysis of … October 4, 2011 The competent surgeon: individual accountability in the era of "systems" failure

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44190/psn-pdf
    June 03, 2015 - health care safety efforts after her daughter died due to a series of medical mistakes, including failure … pulse-center-patient-safety-education-advocacy https://psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case … https://psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34728/psn-pdf
    December 19, 2016 - Forgive and Remember: Managing Medical Failure. 2nd ed. … https://psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed In this seminal study … https://psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34737/psn-pdf
    November 19, 2015 - First, Do No Harm Part 1: A Case Study of Systems Failure. … https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure This video, produced … https://psnet.ahrq.gov/issue/first-do-no-harm-part-1-case-study-systems-failure https://psnet.ahrq.gov

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49514/psn-pdf
    July 01, 2006 - A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure … The patient had two apparent indications for an ACE inhibitor: type 2 diabetes and congestive heart failure … predispose to hyperkalemia—diabetes because of hyporeninemic hypoaldosteronism and congestive heart failure … In the Randomized Aldactone Evaluation Study (RALES), only 1.7% of heart failure patients treated with … The effect of spironolactone on morbidity and mortality in patients with severe heart failure.

  6. Section4 (pdf file)

    hcup-us.ahrq.gov/reports/factsandfigures/2008/pdfs/section4.pdf
    January 01, 2008 -  Between 1997 and 2008, costs for acute renal failure, septicemia, and respiratory failure grew at … implant or graft 5.7 8.4 11.5 2.5 2.8 3.1 6.5 Congestive heart failure … other back problems 3.6 6.2 9.5 1.6 2.0 2.6 9.4 Respiratory failure … , septicemia, and respiratory failure grew at two to three times the rate of total hospital costs. … , mood disorders, and acute renal failure

  7. Exhibit 4.1 Cost by Diagnosis

    hcup-us.ahrq.gov/reports/factsandfigures/2008/figures/2008_4_1b.jsp
    January 01, 2008 - AGGREGATE COSTS IN BILLIONS MEAN COST Mood disorders 824 $4.2 $5,100 Acute renal failure … 798 $7.4 $9,300 Acute cerebrovascular disease 565 $7.6 $13,400 Respiratory failure … back problems 663 $9.5 $14,400 Pneumonia 1,156 $10.5 $9,000 Congestive heart failure

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46773/psn-pdf
    January 24, 2018 - /issue/patient-safety-complementary-medicine-through-application-clinical-risk- management-public Failure … This study describes the application of failure mode and effect analysis to better understand the patient … patient-safety-complementary-medicine-through-application-clinical-risk-management-public https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33653/psn-pdf
    June 01, 2007 - In response to "Failure to Report" (March 2007) June 1, 2007 Paparella S, Vaida AJ, Spath P. … In response to "Failure to Report" (March 2007). PSNet [internet]. 2007. … https://psnet.ahrq.gov/perspective/response-failure-report-march-2007 In response to "Failure to Report … the vials that accompanied the commentary, we felt that https://psnet.ahrq.gov/perspective/response-failure-report-march … -2007 https://psnet.ahrq.gov/web-mm/failure-report the manufacturers had done a fairly good job of

  10. One ACE Too Many | PSNet

    psnet.ahrq.gov/web-mm/one-ace-too-many
    June 21, 2016 - A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure … The patient had two apparent indications for an ACE inhibitor: type 2 diabetes and congestive heart failure … predispose to hyperkalemia—diabetes because of hyporeninemic hypoaldosteronism and congestive heart failure … In the Randomized Aldactone Evaluation Study (RALES), only 1.7% of heart failure patients treated with … The effect of spironolactone on morbidity and mortality in patients with severe heart failure.

  11. Trends in Observed Adult Inpatient Mortality for High-Volume Conditions, 2002-2012 #194

    hcup-us.ahrq.gov/reports/statbriefs/sb194-Inpatient-Mortality-High-Volume-Conditions.jsp
    July 01, 2015 - decreasing for high-volume conditions, such as acute myocardial infarction (AMI), congestive heart failure … 41 percent decrease for acute myocardial infarction (AMI), 29 percent decrease for congestive heart failure … the number of deaths per 1,000 hospital admissions for acute myocardial infarction, congestive heart failure … Deaths per 1,000 hospital admissions for congestive heart failure were 44.4 in 2002, 42.5 in 2003, 41.3 … primary payer, 2002-2012 Abbreviations: AMI, acute myocardial infarction; CHF, congestive heart failure

  12. Section5 9 (pdf file)

    hcup-us.ahrq.gov/reports/factsandfigures/2007/pdfs/section5_9.pdf
    January 01, 2007 - 100.0% 100.0% 27% Non-specific chest pain 48 91 13.4 20.3 91 Congestive heart failure … Appendicitis 27 46 8.8 11.1 68 Respiratory 527 537‡ 100.0 100.0 2 Respiratory failure … disorders) 147 193 31.0 36.3 32 Genitourinary 152 195 100.0 100.0 28 Acute renal failure … Medicaid hospital stays for some conditions more than doubled from 1997 to 2007:  Acute renal failure …  Respiratory failure (up 125 percent).  Anemia (up 118 percent).

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45599/psn-pdf
    July 02, 2017 - combined the narratives of various critical care nurses into four representative scenarios demonstrating failure … environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue … invisible-gorilla-and-other-ways-our-intuitions-deceive-us https://psnet.ahrq.gov/issue/escalation-care-and-failure-rescue-multicenter-multiprofessional-qualitative-study

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47756/psn-pdf
    February 06, 2019 - psnet.ahrq.gov/issue/meltdown-why-our-systems-fail-and-what-we-can-do-about-it Complex systems are prone to failure … This book provides a multi-industry discussion of factors that contribute to failure. … highlight how complexity can exacerbate problems, small glitches can manifest themselves in large-scale failure

  15. Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category (pdf file)

    pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
    January 01, 2019 - resulting in transfer to an acute-care hospital and contributing to death • Pneumonia and respiratory failure … treated with ineffective medication for several days, leading to increased bruising, respiratory failure … Cascade with septic shock related to urinary catheter with delayed recognition leading to respiratory failure … contributing to death • Fungal central line-associated bloodstream infection leading to acute renal failure … , requiring acute-care hospital care, and ultimately death • Altered mental status and respiratory failure

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45393/psn-pdf
    November 16, 2016 - for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure … for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure … independent physician chart review to assess the reliability of PSI 11 (postoperative respiratory failure

  17. HCUP-hospital-readdmission-infographic-34-51-12-Final(s) (pdf file)

    hcup-us.ahrq.gov/reports/infographics/HCUP-hospital-readmission-infographic-final.pdf
    July 15, 2014 - , infection, or burn patients with these common diagnoses was readmitted: 25% Congestive heart failure … 22% Schizophrenia 22% Acute and unspecified renal failure patients with these less frequent … readmissions than other payers Procedure: Amputation of lower extremity Diagnosis: Congestive heart failure

  18. Exhibit 4.2 Cost Factors Accounting for Growth by Diagnosis

    hcup-us.ahrq.gov/reports/factsandfigures/2008/figures/2008_4_2.jsp
    January 01, 2008 - ANNUAL GROWTH IN DISCHARGES PER POPULATION AVERAGE ANNUAL GROWTH IN POPULATION Acute renal failure … care, fitting of prostheses, and adjustment of devices 2.2% 1.7% -0.6% 1.0% Respiratory failure … 3.5% -1.8% 1.0% Cardiac dysrhythmias 6.6% 3.5% 2.0% 1.1% Congestive heart failure

  19. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
    March 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case March 2007 Failure to Report Source and Credits This … Case: Failure to Report Several hours later, when removing another vial of ceftriaxone from the automated … of safe guards RN failure to confirm med identity prior to administration An environment predisposed … Case: Failure to Report (cont.) … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=10720336 Failure to Acknowledge Errors Even when

  20. Dental Recommendations for Preventing Complications in Patients with Chronic Conditions Health Partners Research Foundation eDent Study (pdf file)

    digital.ahrq.gov/sites/default/files/docs/resource/James_Fricton_IQHIT_Q1_HP_Recommendations_for_Preventing_Complications_for_Chronic_Illnesses.pdf
    January 01, 2005 - Renal failure f. Thyrotoxicosis g. Chronic obstructive lung disease 3. … Asymptomatic heart failure, previous MI, LV dysfunction, valvular heart disease III. … Renal failure f. Thyrotoxicosis g. Chronic obstructive lung disease 3. … Asymptomatic heart failure, previous MI, LV dysfunction, valvular heart disease III. … The incidence and prevalence of congestive heart failure in Rochester, Minnesota.
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