-
www.ahrq.gov/sites/default/files/2024-04/eskandari-raval-report.pdf
January 01, 2024 - follow-up to 90 days, preoperative screening for
high-risk patients, and investigation of prophylaxis failure
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
February 01, 2011 - .
*
Consequences
Failure to recognize gaps in competence can result in patient harm
This case highlights
-
www.ahrq.gov/hai/pfp/interimhac2014-ap1.html
November 01, 2015 - 2013)
Post-Op Hemorrhage or Hematoma (PSI 9)
20,000
0.61
PSI (2013)
Post-Op Respiratory Failure
-
psnet.ahrq.gov/node/49652/psn-pdf
May 01, 2012 - Extra dose ADEs
are commonly associated with a failure of communication and/or missing information.
-
www.ahrq.gov/research/findings/final-reports/ptflow/section3.html
April 01, 2020 - production environment or a consumer-oriented service industry, variation invariably precedes system failure
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/prevent/leg-bags-faqs.html
July 01, 2017 - potential safety risk to the resident (e.g., infection, compromised structural integrity leading to device failure
-
www.ahrq.gov/news/newsletters/e-newsletter/961.html
June 01, 2025 - improving the quality of care and outcomes for critically ill or injured children experiencing respiratory failure
-
digital.ahrq.gov/ahrq-funded-projects/evaluating-diagnostic-decision-support-systems-patients-requiring-urgent
July 01, 2023 - The failure to seek timely care can lead to poor outcomes.
-
www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/child-maltreatment-primary-care-interventions
May 19, 2022 - abuse perpetrated by a parent or caretaker against a child (not parent reported)
Physical (e.g., failure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/emerging/emerging.doc
January 01, 2001 - · Heart failure.
· Pneumonia (community acquired).
-
psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - 2011 Boston Globe investigation
identified more than 200 deaths over a 5-year period attributable to failure
-
www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/vitamin-d-calcium-or-combined-supplementation-for-the-primary-prevention-of-fractures-in-adults-preventive-medication
June 23, 2016 - disorders, celiac disease, cystic fibrosis, short gut syndrome, cholestatic liver disease, hepatic failure
-
www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/vision-in-children-ages-6-months-to-5-years-screening
December 17, 2015 - Astigmatism: Blurred vision caused by a failure to focus light evenly onto the retina because of deviation
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-ref.html
September 01, 2023 - Perspectives on diagnostic failure and patient safety. Healthc Q 2012;15 Spec No:50-6.
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/data-analysis-webcast-advancing-methods-4.pdf
March 03, 2021 - team throughout
• Practice, Practice, Practice
• Keep focus on process improvement and off of people failure
-
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
-
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
-
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.
-
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
-
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