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Showing results for "failure".

  1. AHRQ Grant Final Progress Report: Improving Patient Safety Through Provider Communication Strategy Enhancements (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/daugherty-report.pdf
    January 01, 2024 - and placed them in the following four categories: communications that were too late to be effective; failure

  2. AHRQ Safety Program for Surgery: Final Report (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/safe_surgery_finalreport.pdf
    December 01, 2017 - In addition, the various stakeholders often define success and failure in differential and sometimes … In a four-year program with multiple cohorts, CEs, and a NPT, definitions of success and failure evolve … They also believed that retribution for reporting the failure of others to follow procedures was natural … Several sites told tales of failure. … By the same token, when team members were asked what failure would look like, they said a “failure to

  3. Nis 2014 Maskedstats Core (pdf file)

    hcup-us.ahrq.gov/db/nation/nis/tools/stats/NIS_2014_MaskedStats_Core.PDF
    January 01, 2014 - W CC 3,811 0.05% 188: PLEURAL EFFUSION W/O CC/MCC 1,036 0.01% 189: PULMONARY EDEMA & RESPIRATORY FAILURE … & SHOCK W MCC 69,693 0.99% 292: HEART FAILURE & SHOCK W CC 74,716 1.06% 293: HEART FAILURE & SHOCK … W MCC 42,144 0.60% 683: RENAL FAILURE W CC 60,831 0.86% 684: RENAL FAILURE W/O CC/MCC 12,072 0.17% … 133,111 1.88% 107: Cardiac arrest and ventricular fibrillation 4,530 0.06% 108: Congestive heart failure … vomitus 31,479 0.45% 130: Pleurisy; pneumothorax; pulmonary collapse 21,281 0.30% 131: Respiratory failure

  4. Nis 2014 Maskedstats Core Weighted (pdf file)

    hcup-us.ahrq.gov/db/nation/nis/tools/stats/NIS_2014_MaskedStats_Core_Weighted.PDF
    January 01, 2014 - W CC 19,055 0.05% 188: PLEURAL EFFUSION W/O CC/MCC 5,180 0.01% 189: PULMONARY EDEMA & RESPIRATORY FAILURE … ENDOCARDITIS W CC 2,895 0.01% 290: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC 650 0.00% 291: HEART FAILURE … & SHOCK W MCC 348,465 0.99% 292: HEART FAILURE & SHOCK W CC 373,580 1.06% 293: HEART FAILURE & SHOCK … W CC 14,390 0.04% 675: OTHER KIDNEY & URINARY TRACT PROCEDURES W/O CC/MCC 2,100 0.01% 682: RENAL FAILURE … W MCC 210,720 0.60% 683: RENAL FAILURE W CC 304,155 0.86% 684: RENAL FAILURE W/O CC/MCC 60,360 0.17%

  5. Home and Community-Based Services Quality Indicators: (pdf file)

    qualityindicators.ahrq.gov/Downloads/Resources/Publications/2012/Appendix_1A_Details_of_literature_review.pdf
    January 01, 2012 - conditions covered by the AHRQ Prevention Quality Indicators (PQIs)1 (diabetes, congestive heart failure … "Congestive heart failure and Alzheimer's disease." Neurol Res 28(6): 588-94. … For instance, some people may consider excessive use of restraints to be abuse, or failure to provide … "Effect of pharmaceutical care services on outcomes forh.ome care patients with heart failure." … to administer life-saving”, “Failure to prevent medication interaction”, “Failure to prevent prescription

  6. Nis 2013 Maskedstats Core (pdf file)

    hcup-us.ahrq.gov/db/nation/nis/tools/stats/NIS_2013_MaskedStats_Core.PDF
    January 01, 2013 - W CC 4,030 0.06% 188: PLEURAL EFFUSION W/O CC/MCC 1,095 0.02% 189: PULMONARY EDEMA & RESPIRATORY FAILURE … & SHOCK W MCC 63,792 0.90% 292: HEART FAILURE & SHOCK W CC 73,857 1.04% 293: HEART FAILURE & SHOCK … W MCC 39,932 0.56% 683: RENAL FAILURE W CC 60,339 0.85% 684: RENAL FAILURE W/O CC/MCC 12,465 0.18% … 141,912 1.99% 107: Cardiac arrest and ventricular fibrillation 4,161 0.06% 108: Congestive heart failure … vomitus 33,292 0.47% 130: Pleurisy; pneumothorax; pulmonary collapse 21,651 0.30% 131: Respiratory failure

  7. Nrd 2014 Maskedstats Core (pdf file)

    hcup-us.ahrq.gov/db/nation/nrd/stats/NRD_2014_MaskedStats_Core.PDF
    January 01, 2014 - W CC 8,771 0.06% 188: PLEURAL EFFUSION W/O CC/MCC 2,483 0.02% 189: PULMONARY EDEMA & RESPIRATORY FAILURE … ENDOCARDITIS W CC 1,324 0.01% 290: ACUTE & SUBACUTE ENDOCARDITIS W/O CC/MCC 293 0.00% 291: HEART FAILURE … & SHOCK W MCC 157,971 1.06% 292: HEART FAILURE & SHOCK W CC 175,306 1.18% 293: HEART FAILURE & SHOCK … W MCC 92,540 0.62% 683: RENAL FAILURE W CC 137,564 0.92% 684: RENAL FAILURE W/O CC/MCC 28,767 0.19% … 302,753 2.03% 107: Cardiac arrest and ventricular fibrillation 9,501 0.06% 108: Congestive heart failure

  8. Screening for Obstructive Sleep Apnea in Adults: Evidence Report and Systematic Review for the USPSTF (pdf file)

    www.uspreventiveservicestaskforce.org/home/getfilebytoken/Rm4E5SooP2GnqJ_HVRA5M4
    January 01, 2017 - Mortality Quality of life Motor vehicle crashes Cardiovascular events Cerebrovascular events Heart failure … related mortality,145 nonfatal cardiovascular events,12 heart failure,148 coronary heart disease,148 … Auto-titrating continuous positive airway pressure therapy in patients with chronic heart failure and … Inhibition of awake sympathetic nerve activity of heart failure patients with obstructive sleep apnea … Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the

  9. Environmental Scan of Patient Safety Education and Training Programs (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
    June 01, 2013 -  Health Care Failure Mode and Effects Analysis (HFMEA)—a five-step process that uses an interdisciplinary … For example, if Error Analysis is selected, then Failure Mode and Effects Analysis, Narrative/Storytelling … Cause and Effect Diagramming' ‘Designing for Safety' ‘Evaluation of Patient Safety Programs' ‘Failure … Mode and Effects Analysis (HFMEA) ‘Healthcare Failure Modes and Effects Analysis (HFMEA)' ‘Heuristic … Teamwork Training 0 619 Error Reporting and Analysis 206 625 -- Error Analysis 185 627 ---- Failure

  10. In Conversation with...Dean Schillinger, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
    March 01, 2009 - For a patient with heart failure, this means making sure I really understand whether this person has … WebM&M Cases Recurrent Hypoglycemia: A Care Transition Failure

  11. Rapid Response Teams: Lessons from the Early Experience | PSNet

    psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
    November 01, 2005 - patients receiving care that could prevent a code blue.( 6 ) This overall construct is sometimes called failure … WebM&M Cases Mismanagement of Acute Decompensated Heart Failure

  12. 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
    January 01, 2006 - such, the scorecard is an integration of multiple interventions and keeps “score” of the success or failure … This concept utilizes prospective risk assessment tools, such as failure modes and effects analysis

  13. Archived: Evidence Summary: Obstructive Sleep Apnea in Adults: Screening | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/obstructive-sleep-apnea-in-adults-screening-january-2017
    January 24, 2017 - of the following outcomes: cancer-related mortality, 145 nonfatal cardiovascular events, 12 heart failure … Cardiac function after CPAP therapy in patients with chronic heart failure and sleep apnea: a multicenter … Inhibition of awake sympathetic nerve activity of heart failure patients with obstructive sleep apnea … Auto-titrating continuous positive airway pressure therapy in patients with chronic heart failure and … Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the

  14. DARTNet Summary Report (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/distributed-network-ambulatory-therapeutics_research.pdf
    July 01, 2009 - Rates of hypoglycemia, liver injury, and liver failure were rare, and did not differ substantially … Examine comparative safety of medication related adverse events as measured by liver failure, liver … COMPARATIVE SAFETY  Crude rates of hypoglycemia, liver injury, and liver failure were relatively low … Rates of hypoglycemia, liver injury, and liver failure were determined from EHR data. … As was the case in Phase 1, rates of hypoglycemia, liver injury, and liver failure were rare and did

  15. THE HCUP NATIONWIDE READMISSIONS DATABASE (NRD), 2013

    hcup-us.ahrq.gov/db/nation/nrd/NRD_Introduction_2013.jsp
    January 01, 2013 - Consider the following example: A patient with congestive heart failure has a 3-day hospital admission … Same State as the Index Event Readmissions Considered from Any State 108: Congestive heart failure … Acute cerebrovascular disease 232,510 14.73 15.23 3.4 157: Acute and unspecified renal failure … Pleurisy; pneumothorax; pulmonary collapse 37,794 25.02 25.81 3.1 131: Respiratory failure … ; nephrosis; renal sclerosis 1,488 25.00 25.54 2.2 157: Acute and unspecified renal failure

  16. Archived: Evidence Summary: Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary25/screening-for-abnormal-blood-glucose-and-type-2-diabetes-october-2015
    April 13, 2015 - increased, from approximately 5% in 1995 to 8% in 2010. 3 Diabetes is the leading cause of kidney failure … withdrawal because of adverse events. 47 Rosiglitazone was associated with increased congestive heart failure … mortality, cardiovascular morbidity (including myocardial infarction, stroke, and congestive heart failure … 5: Mortality, cardiovascular morbidity (including myocardial infarction, stroke, congestive heart failure … B MI: 0% (0/103) vs. 1% (1/104); RR, 0.34 (95% CI, 0.01 to 8.17) Congestive heart failure: 0%

  17. Disposition of Comments Report for Treatment of Atrial Fibrillation (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/atrial-fibrillation_disposition-comments.pdf
    June 28, 2013 - June 28, 2013 6 Commentator & Affiliation Section Comment Response TEP #7 General The failure … Mortality (all-cause, cardiac) o Myocardial infarction o Cardiovascular hospitalizations o Heart failure … analysis of the RAFT Trial suggests that there is no proven benefit for CRT in patients with heart failure … In my opinion, failure to discuss earlier studies greatly limits the validity of the authors’ conclusions … studies and comparisons by particular components of endpoints, such as “hospitalization for heart failure

  18. Using IT to Improve Medication Safety for Rural Elders - 2008 | Digital Healthcare Research

    digital.ahrq.gov/ahrq-funded-projects/using-information-technology-it-improve-medication-safety-rural-elders/annual-summary/2008
    January 01, 2008 - Using IT to Improve Medication Safety for Rural Elders - 2008 Project Name Using Information Technology (IT) to Improve Medication Safety for Rural Elders Principal Investigator Gorman, Paul Organization Samaritan North Lincoln Hospital Funding Mechanism HS04-011: T…

  19. Creating Psychological Safety in Teams (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/psychological-safety.pdf
    June 02, 2025 - Creating Psychological Safety in Teams Creating Psychological Safety in Teams Creating Psy…

  20. Section 3: Teaching Introductory Material | Agency for Healthcare Research and Quality

    www.ahrq.gov/teamstepps-program/curriculum/intro/teach.html
    August 01, 2023 - Section 3: Teaching Introductory Material TeamSTEPPS 3.0 has been taught in a two-day format, is often taught in a half-day format, and is also frequently taught in smaller segments only 15–30 minutes long. While in-person trainings have been the norm, virtual trainings using an online platform are now common a…
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