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Showing results for "failure".

9621. Module 3: Best Practices in Pressure Injury Prevention (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices.docx
      June 02, 2025 - The failure to have clear admission documentation led to an increase in the documentation of hospital-acquired … ongoing complex medical care and a need for management of advanced Parkinson’s disease, dysphagia, and failure

9622. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
      January 01, 2024 - • In this case, failure to diagnosis acute alcohol intoxication (AAI) mimicking stroke led to overdiagnosis … Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009;64(6):515-526.

9623. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/864867/psn-pdf
      April 10, 2024 - In this case, failure to diagnosis acute alcohol intoxication (AAI) mimicking stroke led to overdiagnosis … Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009;64(6):515-526.

9624. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865429/psn-pdf
      April 24, 2024 - Investigate unexpected events immediately The failure to connect the cardioverter/defibrillator to the … This incident was due to human error rather than equipment failure, although there were likely multiple

9625. Presentation: Science of Improving Patient Safety and Identifying Defects
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
      December 01, 2017 - Teamwork and communication: communication failure: basic components, contributing factors, and the call … Teamwork and communication: communication failure: basic components, contributing factors, and the call

9626. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33859/psn-pdf
      June 01, 2018 - The primary care providers wanted to be able to manage congestive heart failure, look at right upper … teaching tool to explain to patients why, for example, they have to take three medications for heart failure

9627. Design Options for a Self-Management Support Program (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptmgmt/design2.html
      July 01, 2018 - As an example, an external call-center program for heart failure patient support stratified participants … (people identified with heart failure who agreed to enroll) into three categories of high, medium, and

9628. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet
      psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
      May 26, 2021 - human factors. 15,16 These errors are associated with prescribing (incomplete or contradictory orders, failure … include activation of PCA by others (usually well-meaning family, or “PCA by proxy”) and equipment failure

9629. Infection After Carpal Tunnel Surgery | PSNet
      psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
      May 28, 2014 - Failure to Diagnose and Treat Post-Surgery Infection Leads to $1.18 Million Verdict. … July 19, 2023 WebM&M Cases Open wider: Failure to use

9630. Implementing Hybrid Cardiac Rehabilitation to Expand Access and Capacity
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/hycr-consolidated-slides.pptx
      May 11, 2023 - Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized … coordination of patient care Potential implementation delays Greater available resources for implementation Failure

9631. Hospital Stays Resulting from Excessive Heat and Cold Exposure Due to Weather Conditions in U.S. Community Hospitals, 2005 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb55.pdf
      July 01, 2008 - heat-related hospitalizations included fluid and electrolyte disorders (7.6 percent of stays), renal failure … 1,159 Heat collapse 232 2 Fluid and electrolyte disorders 484 (7.8) 3 Acute and unspecified renal failure

9632. In Conversation With… Brian Jarman, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
      March 01, 2015 - They had some problems with young men having organ failure in a drug trial, and they'd had some excess … considerably.( 9 ) Certain comorbidities that impact on mortality (such as morbid obesity, dementia, and heart failure

9633. Statistical Brief #68: Hospitalizations for Brain Cancer, 2006 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb68.pdf
      March 01, 2009 - patients—pneumonia, septicemia, pulmonary heart disease, aspiration pneumonitis, and respiratory failure … nervous system conditions 600 0.8% 19 Aspiration pneumonitis, food/vomitus 600 0.8% 20 Respiratory failure

9634. Redesigning Primary Health Care Teams for Population Health and Quality Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/delivery-initiative/redesigningprimaryhealthcareteams.html
      November 01, 2017 - Training included disease-specific modules on hypertension, chronic heart failure, asthma, and diabetes … Choosing Wisely (patient education) Chronic disease management Competency checklist Congestive heart failure

9635. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73906/psn-pdf
      October 06, 2021 - That was a failure to not have an interpreter, have a Spanish-speaking clinician, or have a handout … KH: It reminds me of some of the work in patient safety around the use of Failure Mode and Effects Analysis

9636. Missed Opportunities for Suicide Risk Assessment | PSNet
      psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
      September 27, 2023 - Presentation March 27, 2024 WebM&M Cases Failure … September 27, 2023 WebM&M Cases Failure to Adhere

9637. A Loss of Trust and a Missed Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
      October 31, 2023 - Acute back pain should generally not be managed with opioid analgesics; instead, failure of symptom improvement … Coming Up Short October 1, 2008 WebM&M Cases Failure

9638. NIS Description of Data Elements
      hcup-us.ahrq.gov/db/nation/nis/nisdde.jsp
      February 01, 2025 - Severity (not in Q4) CM_CHF AHRQ comorbidity measure for ICD-9-CM codes: congestive heart failure … Q1Q3 Severity (not in Q4) CM_RENLFAIL AHRQ comorbidity measure for ICD-9-CM codes: renal failure

9639. Services (pdf file)
      meps.ahrq.gov/data_stats/nhc/services.pdf
      September 30, 1997 - (US36) RENAL FAILURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … GASTROINTESTINAL HEMORRHAGE HYPERTENSION INTESTINAL OBSTRUCTION MYOCARDIAL INFARCTION PNEUMONIA RENAL FAILURE

9640. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-psychological-safety.pdf
      September 01, 2023 - approaches to learn from diagnostic quality and develop strategies to reduce harm from diagnostic failure … Perspectives on diagnostic failure and patient safety. Healthc Q. 2012;15 Spec No:50-6.