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Showing results for "failure".

9281. Patient Safety and Quality Improvement Act of 2005; Public Law 109–41, July 29, 2005 (pdf file)
      pso.ahrq.gov/sites/default/files/Patient%20Safety%20Act%20PDF.pdf
      January 01, 2025 - purposes of this subsection, an ‘adverse employment action’ includes— ‘‘(A) loss of employment, the failure … to promote an individual, or the failure to provide any other employment- related benefit for which

9282. Patient Safety and Quality Improvement Act of 2005; Public Law 109–41, July 29, 2005 (pdf file)
      pso.ahrq.gov/sites/default/files/wysiwyg/Patient-Safety-Act-2005.pdf
      January 01, 2005 - purposes of this subsection, an ‘adverse employment action’ includes— ‘‘(A) loss of employment, the failure … to promote an individual, or the failure to provide any other employment- related benefit for which

9283. Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
      April 06, 2008 - near misses that can become an adverse event; (2) trending, to gain insight into the distribution of failure … .14 The incident causation model developed by Van der Schaaf19 has four components: (1) initial failure

9284. Table of Contents: Volume 1. Assessment (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
      January 01, 2025 - Failure Modes and Effects Analysis Based on in Situ Simulations: A Methodology to Improve Understanding

9285. 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.

9286. Making Healthcare Safer IV Rapid Review: Examining the Impact of Implementing High-Reliability Organization Principles on Patient Safety Outcomes (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/hro-rapid-research.pdf
      May 01, 2025 - Organization Principles 1. sensitivity to operations; 2. reluctance to simplify; 3. preoccupation with failure … two pillars: anticipation (sensitivity to operations, reluctance to simplify, preoccupation with failure … assessment of potential risks and plans to mitigate those risks could signal a healthy preoccupation with failure

9287. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49607/psn-pdf
      August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…

9288. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33881/psn-pdf
      August 01, 2019 - In Conversation With… Erik Hollnagel, PhD June 1, 2019 In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting…

9289. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49423/psn-pdf
      November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…

9290. 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

9291. 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

9292. Toolkits | PSNet
      psnet.ahrq.gov/toolkits
      March 01, 2025 - ) Error Reporting and Analysis (41) Error Analysis (15) Failure

9293. Advances in Patient Safety: New Directions and Alternative Approaches | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
      July 01, 2022 - Failure Mode and Effects Analysis Based on In-Situ Simulations: A Methodology to Improve Understanding

9294. Eptifibatide Epilogue | PSNet
      psnet.ahrq.gov/web-mm/eptifibatide-epilogue
      March 04, 2011 - analysis of more than 2400 sentinel events indicated that the root cause of error was communication failure

9295. Breakage of a PICC Line | PSNet
      psnet.ahrq.gov/web-mm/breakage-picc-line
      June 21, 2023 - December 31, 2014 WebM&M Cases Communication Failure—Who's

9296. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49584/psn-pdf
      April 01, 2009 - federal government and many payers seek to subsidize and/or reward physicians' EMR use and to penalize "failure

9297. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852808/psn-pdf
      August 30, 2023 - Precipitating factors for DKA include infections, new-onset diabetes, insulin pump failure or missed

9298. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
      January 01, 2023 - – Precipitating factors for DKA include infections, new-onset diabetes, insulin pump failure or

9299. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49437/psn-pdf
      March 01, 2004 - Central vein catheterization: failure and complication rates by three percutaneous approaches.

9300. Dangerous Dialysis | PSNet
      psnet.ahrq.gov/web-mm/dangerous-dialysis
      June 12, 2024 - the "Wild" December 1, 2014 WebM&M Cases Failure