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Showing results for "failure".

9901. TeamSTEPPS Video-Based Simulation: Facilitator Guide Module 2 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/module-2-team-leadership-facilitator-guide.pdf
      June 02, 2025 - unreliable, download video files to your device (computer or storage device) to avoid risk of internet failure … This failure to prioritize their input provides an opportunity to discuss how to include the patient

9902. Debrief Example Audio Transcript/Facilitator Notes - Implementation Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-k-debrief-fac-notes.html
      May 01, 2017 - And if the test is an utter failure, then you're only going to affect a small volume of the cases coming … That could set you up for failure right from the start.

9903. Appendix-K-Debrief-Audio-Facnotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-debrief-audio-facnotes.docx
      June 02, 2025 - And if the test is an utter failure, then you're only going to affect a small volume of the cases coming … That could set you up for failure right from the start.

9904. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing | PSNet
      psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
      August 21, 2005 - warfarin in patients with a CrCl < 15 ml/min. 5  Additionally, drug interactions and significant organ failure … WebM&M Cases Recurrent Hypoglycemia: A Care Transition Failure

9905. Artificial Intelligence Tools to Improve Provider Effectiveness and Patient Outcomes (pdf file)
      digital.ahrq.gov/sites/default/files/docs/artificial-intelligence-tools-improve-slides-03182025.pdf
      March 18, 2025 - Outcome Definitions Respiratory Failure: requiring high-flow O2 (≥ 6L), NIPPV or mechanical ventilation … ; Cardiovascular Failure: hypotension requiring vasopressors; Moderate Respiratory Dysfunction: SpO2

9906. Artificial Intelligence (AI) in Healthcare Safety Program: October 2024 Update (pdf file)
      pso.ahrq.gov/sites/default/files/wysiwyg/ai-healthcare-safety-program.pdf
      July 01, 2025 - involved an HIT device and included a device event description (Data Element 156), device defect or failure … was most commonly reported (32.2%), with use error, combination of use error and device defect or failure

9907. Final Progress Report: Evaluating safety and quality of tracheal intubation in pediatric ICUs (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/nishisaki2-report.pdf
      January 01, 2025 - 13.2% 8.8% 19.1% 3.1% 10.5% 15.5% 5.5% 0.0% 16.4% 9.1% 18.9% 2.8% 10.7% Oxygenation failure … 39.3% 34.4% 0.08 51.3% 34.4% <0.001 Ventilation failure 37.9% 33.5% 0.11 47.8% 33.5% 0.002

9908. Best Practices in the Diagnosis and Treatment of Sepsis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/sepsis-facilitator-guide.pdf
      November 01, 2019 - A more recent approach is the use of the sequential organ failure assessment, or SOFA, score, in which … day mortality, but administration of gentamicin was slightly associated with development of renal failure

9909. Final Progress Report: Hospital Volume and Quality of Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/picone-jollis-report.pdf
      January 01, 2024 - on admission electrocardiogram, Killip class, left ventricular ejection fraction, congestive heart failure … attack patients are classified into one of four classes: those with no evidence of congestive heart failure

9910. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
      May 01, 2011 - for second-victims: Patient or family “connects” with staff member Pediatric cases Medical errors Failure-to-rescue … : When a patient or family “connects” or bonds with a staff member Pediatric cases Medical errors Failure-to-rescue

9911. NAA National Webinar May 2024 - Understanding and Operationalizing the National Action Alliance Aim #1: Advance Organizational Safety Strategies Using National Action Plan Foundations (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/advance-organizational-safety-strategies-slides.pdf
      June 18, 2024 - Strategies Healing without Harm: Zero Preventable Harm HIGH RELIABILITY ORGANIZATION Preoccupation with failure … Governance • Patient/Member and Family Engagement • Workforce Safety • Learning System Preoccupation with failure

9912. In Conversation with...Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
      October 01, 2010 - For example, in one aviation checklist the emergency procedures covered a two-engine failure at altitude … but not failure near the ground when there was little time to react.( 11 ) Including all scenarios requires

9913. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/neumiller.html
      August 01, 2017 - relevant information to subsequent providers. 29 Furthermore, confusion in lines of authority and failure … Lastly, serious ADEs were defined as those that could potentially result in significant organ failure

9914. What Makes a Good Checklist | PSNet
      psnet.ahrq.gov/perspective/what-makes-good-checklist
      October 01, 2010 - For example, in one aviation checklist the emergency procedures covered a two-engine failure at altitude … but not failure near the ground when there was little time to react.( 11 ) Including all scenarios requires

9915. Intraosseous Line Extravasation in a Pediatric Trauma Patient | PSNet
      psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
      September 29, 2021 - blood and other fluids via the bone marrow in traumatic shock and other forms of peripheral circulatory failure … Failure of pulse oximetry in the assessment of raised limb intracompartmental pressure.

9916. Quality Indicators Sensitive to Nurse Staffing in Acute Care Settings (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Savitz.pdf
      March 01, 2004 - Provisional NQF (n=13) ANA (n=10) Death in low mortality DRG X Decubitus/pressure ulcer X X X Failure … virtually no direct overlap in these measure sets, with the exception of decubitus/pressure ulcer and failure

9917. Trends and Projections in Hospital Stays for Adults With Multiple Chronic Conditions, 2003-2014 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb183-Hospitalizations-Multiple-Chronic-Conditions-Projections-2014.pdf
      January 01, 2014 - condition Clinical coding criteria Hypertension CCS 98, 99 Hyperlipidemia CCS 53 Congestive heart failure … conditions as applied to the NIS: Chronic kidney disease was misidentified as CCS 108 (Congestive heart failure

9918. CER 215 Executive Summary: Adverse Effects of Pharmacologic Treatments of Major Depression in Older Adults (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-215-depression-older-adults-executive-summary.pdf
      March 01, 2019 - Readers should not assume a failure to find a difference means that the given interventions are similar … placebo-controlled treatment trial of citalopram for major depressive disorder in older patients with heart failure

9919. Statistical Brief #125
      hcup-us.ahrq.gov/reports/statbriefs/sb125.jsp
      February 01, 2012 - Stays primarily for circulatory disorders, including congestive heart failure (3.5 percent of cancer-related … 151,800 4.4% Maintenance chemotherapy; radiotherapy 132,100 3.8% Congestive heart failure

9920. Implementation Guide: Toolkit for MRSA Prevention in ICU & Non-ICU Settings (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/123-mrsa-toolkit-implementation-guide.docx
      October 01, 2024 - CUSP Premortem Project Assessment is a proactive way to anticipate potential points and reasons for failure … things could go wrong, and what could be done preemptively to mitigate those potential reasons for failure