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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. 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

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44783/psn-pdf
    January 13, 2016 - black-box-thinking-why-most-people-never-learn-their-mistakes-some-do Medicine and aviation are high-risk industries where failure … black-box-thinking-why-most-people-never-learn-their-mistakes-some-do https://psnet.ahrq.gov/issue/error-management-lessons-aviation https://psnet.ahrq.gov/issue/failure-and-rescue … https://psnet.ahrq.gov/issue/strategies-learning-failure

  4. 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

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45194/psn-pdf
    December 14, 2016 - Wounded care: failure at one Indian Health Service hospital reveals a system in crisis. … https://psnet.ahrq.gov/issue/wounded-care-failure-one-indian-health-service-hospital-reveals-system-crisis … https://psnet.ahrq.gov/issue/wounded-care-failure-one-indian-health-service-hospital-reveals-system-crisis

  6. 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

  7. 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

  8. 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).

  9. 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

  10. 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

  11. 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

  12. 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

  13. Overview of Clinical Conditions With Frequent and Costly Hospital Readmissions by Payer, 2018 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb278-Conditions-Frequent-Readmissions-By-Payer-2018.pdf
    January 01, 2018 - ■ Heart failure was among the top five conditions at index admission with the highest number and … Three respiratory conditions at index admission—COPD, pneumonia, and respiratory failure—accounted for … Three genitourinary conditions at index admission—acute and unspecified renal failure, urinary tract … With the exception of septicemia and heart failure, the principal diagnoses at index admission with … 110,000 5 28.0 30,800 4.3 Private insurance 6,532,900 - 8.7 569,800 100.0 Hepatic failure 12,100 1

  14. Most Frequent Principal Diagnoses for Inpatient Stays in U.S. Hospitals, 2018 (pdf file)

    hcup-us.ahrq.gov/reports/statbriefs/sb277-Top-Reasons-Hospital-Stays-2018.pdf
    January 01, 2018 - Two circulatory conditions—heart failure and AMI—ranked in the top 10 principal diagnoses in 2018 and … Compared with stays for heart failure, stays for AMI were far less common but more expensive on average … Heart failure and osteoarthritis each accounted for 4 percent. … Five circulatory conditions were among the 20 most common principal diagnoses in 2018: heart failure … Among stays for septicemia, heart failure, pneumonia, and diabetes mellitus with complication, mean

  15. 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.

  16. 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

  17. 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

  18. Ff 2009 Section2 (pdf file)

    hcup-us.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_2009_section2.pdf
    January 01, 2009 -  Pneumonia (3.0 percent of all stays) and congestive heart failure (2.6 percent) were the second …  In 2009, acute renal failure was the most rapidly growing condition with an increase of 245 percent …  Pneumonia (3.0 percent of all stays) and congestive heart failure (2.6 percent) were the second …  Stays for both congestive heart failure and coronary atherosclerosis decreased between 1997 and … Congestive heart failure accounted for 37 stays per 10,000 population in 1997 and 33 stays per 10,000

  19. Facts and Figures Exhibit 2.2

    hcup-us.ahrq.gov/reports/factsandfigures/2009/exhibit2_2.jsp
    January 01, 2009 - 4,159 139 135 -3%‡ Pneumonia 1,232 1,165 45 38 -16% Congestive heart failure … Pneumonia (3.0 percent of all stays) and congestive heart failure (2.6 percent) were the second and third … Stays for both congestive heart failure and coronary atherosclerosis decreased between 1997 and 2009. … Congestive heart failure accounted for 37 stays per 10,000 population in 1997 and 33 stays per 10,000 … In 2009, acute renal failure was the most rapidly growing condition with an increase of 245 percent,

  20. 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
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