-
psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar7_pu_measuringrates.pdf
April 01, 2011 - Development of full thickness pressure ulcers may
reflect a system failure or high acuity level.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar5_pu_riskassesst-tools.pdf
January 01, 2012 - Skin failure: a retrospective review of patients
with hospital-acquired pressure ulcers.
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hcup-us.ahrq.gov/reports/factsandfigures/2009/section5_TOC.jsp
January 01, 2009 - Average hospital costs were lower for females than males for congestive heart failure, acute cerebrovascular
-
psnet.ahrq.gov/node/73146/psn-pdf
April 28, 2021 - transplant incidence on home versus in-center
hemodialysis, following peritoneal dialysis technique failure
-
psnet.ahrq.gov/node/50697/psn-pdf
November 27, 2019 - The risk factors for drug-induced QT prolongation include age, bradycardia, left
ventricular failure
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - January 15, 2009
Take-Home Points
Best Practice Options for Nurse Staffing Ratios Include:
Conduct failure
-
psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - ultimately transferred to
the intensive care unit (ICU), intubated, and later died of hypoxic respiratory failure
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www.ahrq.gov/hai/tools/mvp/modules/cusp/physician-staff-engagement-slides.html
March 01, 2017 - Respiratory failure.
Patient injury.
Treatment errors.
-
www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-slides.html
February 01, 2017 - Avoid failure of infection prevention efforts due to "silo mentality."
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www.ahrq.gov/hai/cusp/toolkit/content-calls/zero-clabsi/slides.html
July 01, 2013 - Wheelchair assists booked in advance for unstable ambulatory patients
Stretcher-locking mechanism failure
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-slides.html
July 01, 2023 - Failure Mode Effect Analysis.
Just Culture.
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/spreading-fac-notes.html
December 01, 2017 - In fact, sustaining adaptive work has a high failure rate.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
December 01, 2017 - A program's success or failure can only be determined if staff actually implement the recommended interventions
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement.pptx
May 01, 2017 - Communication failure: basic components, contributing factors, and the call for structure.
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/section4.html
October 01, 2015 - Common indications include respiratory failure, cardiac or pulmonary arrest, laryngeal trauma or edema
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
February 01, 2012 - Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-retention.pdf
April 01, 2022 - understanding of the unique catheter-based issues higher acuity neurocritical care
patients may have
• Failure
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
December 01, 2010 - Skin fails too: acute, chronic, and end-stage skin failure.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
June 01, 2014 - their unit
3
Case: Wandering Off the Floors
A 74-year-old man with a history of congestive heart failure