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Showing results for "failures".

1. PowerPoint Presentation
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
   June 01, 2021 - an opportunity to prevent the same problem from occurring again System design Can result in “latent” failures … Human behavior Can result in “active” failures 3 Changing the System 3 System Failures System failures … Errors that occur because of individual actions Generally readily apparent Examples of active failures … Organizational Influences – Latent failures Unsafe acts – Active failures Unsafe supervision – Latent … 17 Changing the System 17 Review Consider system/active failures which may have led to the problem

2. Patient, Family Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/baker.html
   August 01, 2017 - Type of event seemed to affect what failures clinicians indicated should be disclosed, while type of … event had little effect on what failures patients and family members indicated should be disclosed. … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … We then examined the failures across events to create a common set of failures by the phases of the L … to the clinician rankings of the same failures.

3. Changing-System-Facilitator-Guide (doc file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
   June 01, 2021 - These result in latent failures. … These result in active failures. … Slide 3 System Failures SAY: System failures are considered latent problems. … Slide 4 Active Failures SAY: Active failures occur because of human error. … Does the problem you are addressing involve latent failures, active failures, or both?

4. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
   January 01, 2003 - Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities … 395 Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care … models provide contextual maps of the errors and behaviors that lead to medication delivery system failures … Risk modeling teams then identify the failures that link together, leading to the top-level event. … The models provide contextual maps of the errors and behaviors that lead to system failures so that

5. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
   April 07, 2008 - Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures … Process failures were analyzed for likelihood, severity, and discoverability of occurrence using the … , such as poor logistics, equipment failures, and poor policies/procedures (Table 3). … Four of the failure modes were active failures. … However, despite this knowledge, many process flaws and team failures were identified.

6. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
   July 01, 2023 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

7. Taxonomic Guidance for Remedial Actions (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
   December 23, 2004 - Technical problems (machine failures) 2. Organizational problems 3. … Human performance failures 4. … Of the organizational failures, those easiest to fix (training, and then protocols) come first. … This taxonomy addresses failures in health care settings. … refer to failures in the performance of fine motor skills, and tripping refers to failures in whole

8. Learn-From-Defects-Facilitator-Guide (doc file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
   May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

9. Hand Hygiene Observational Audit Tracking Tool (xls file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
   December 01, 2021 - per Assessment for Job: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 Month … per Assessment for Job: Average # Failures per Audit - - - - - - - - - - #N/A … per Assessment for Location: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 … per Assessment for Location: Average # Failures per Audit - - - - - - - - - - … Skin is intact without open wounds or rashes # Failures

10. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … • Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

11. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/identify/notes.html
    December 01, 2012 - Examples of Defects or Failures That Affect Patient Safety Slide 9. … Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

12. Diagnostic Safety as a Challenge for Healthcare Leadership | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-1.html
    June 01, 2021 - and contribute to death for up to 80,000 patients in U.S. hospitals annually. 1 Evidence suggests failures … Location and Impact of Diagnostic Failures Balogh EP, Miller BT, Ball JR, eds. … Accessed June 1, 2021. 2015 CRICO Strategies National CBS Report: Malpractice Risks in Communication Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

13. Sensemakingnotes (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
    August 08, 2012 - Active failures are also called human error. … Active failures are categorized in three main types: skill-based, rule-based, and knowledge-based. · … Latent conditions are sorted into two categories: technical failures and organizational failures. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

14. Staff Safety Assessment
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
    January 01, 2006 - and Effects Analysis -Probabilistic Risk Assessment Tools to examine defects or failures … Learn from Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … information by residents during rounds Electronic progress note developed Examples of Defects or Failures … Sensemaking and Identifying Defects Identify defects and Sensemaking share several common themes Defects or failures

15. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - Failure Mode and Effects Analysis - Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … 6 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Examples of Defects or Failures … Sensemaking and Learn From Defects Sensemaking and Learn From Defects share several common themes Defects or failures

16. USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ppe-covid19-audit-tracking-tool-userguide.pdf
    April 01, 2021 - The tracking tool only extracts the failures in each category, so you are only required to select "NO … The tab will then automatically calculate how many “Not Met” observations or failures, were recorded … provides a high-level summary of the audit data for your facility, including and the average number of failures … (NO/Not Met) per audit, and a breakdown of where the failures are occurring by both line item and category … The Summary Rates tab provides graphs outlining the average number of failures per audit and the PPE

17. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
    April 01, 2021 - The tracking tool only extracts the failures in each category, so you are only required to select "NO … The tab will then automatically calculate how many “Not Met” observations or failures, were recorded … provides a high-level summary of the audit data for your facility, including and the average number of failures … (NO/Not Met) per audit, and a breakdown of where the failures are occurring by both line item (#1 - … The Summary Rates tab provides graphs outlining the average number of failures per audit and the hand

18. Chapter 2. What is Care Coordination? | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/ncepcr/care/coordination/atlas/chapter2.html
    June 01, 2014 - Perspectives on Care Coordination Successes and failures in care coordination will be perceived (and … and sites are met over time. 4 Patients, their families, and other informal caregivers experience failures … Patients perceive failures in terms of unreasonable levels of effort required on the part of themselves … They also perceive failures in terms of unreasonable levels of effort required on their part in order … Successes and failures in care coordination will be perceived (and may be measured) in different ways

19. Final Progress Report: Medications at Transitions and Clinical Handoffs (MATCH) (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/noskin-report.pdf
    January 01, 2024 - (3) To determine the rate and etiology of medication reconciliation failures within the general medicine … MATCH that other acute care hospitals can use to implement programs to reduce medication reconciliation failures … The effects of health literacy and cognition as risk factors for medication reconciliation failures … Also, early identification and correction of medication reconciliation failures may mitigate or prevent … Medications At Transitions and Clinical Handoffs (MATCH): Risk factors for medication reconciliation failures

20. Getting Started Laying the Groundwork Coordination for Implementing Automatic Referral & Effective Care
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-slides.pptx
    December 31, 2022 - Then use a fishbone diagram to categorize process failures that need to be addressed. … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures