Results

Total Results: 1,569 records

Showing results for "failures".

101. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 1: Why Patient Narratives Matter (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
     July 01, 2023 - explores: ■ How patient-reported experiences can augment other methods of identifying diagnostic failures … Feedback from patient experiences can be useful for addressing diagnostic failures in two distinct ways … That promise holds similar appeal for addressing diagnostic failures.37 As one paper concluded, “Insights … in three broad (somewhat overlapping) categories: delays in diagnosis, missed or misdiagnosis, and failures … event occurred at all.39,47 That may lead to systematic underreporting of more complex diagnostic failures

102. Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blike.pdf
     January 01, 2003 - test the feasibility and validity of using a human simulator to probe care systems for latent system failures … Many other latent system failures were identified (Table 2) and these findings proved to be robust and … These latent failures existed in an actual clinical unit that was providing sedation care. … team collaboration.22 This study supports the finding that, even in training exercises, latent system failures … An analysis of major errors and equipment failures in anesthesia management: considerations for prevention

103. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (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-Webster_76.pdf
     July 18, 2008 - Cognitive errors and the decisionmaking process can be seen as failures in perception, failed heuristics … decisionmaking biases, as recently popularized by Groopman in his book, How Doctors Think.11 These failures … Despite the seemingly esoteric view of cognitive failures, often problems seen in offices and clinics … Solutions must address ineffective communication, lack of teamwork principles, clinical leadership failures … Communication failures: An insidious contributor to medical mishaps.

104. 3 Tk1 T5-Draft Policies And Procedures For The Antimicrobial Stewardship Program Final (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/3_TK1_T5-Draft_Policies_and_Procedures_for_the_Antimicrobial_Stewardship_Program_final.pdf
     October 01, 2016 - The use of this procedure can help reduce unnecessary prescribing and lead to fewer antibiotic failures

105. Sustainability and the Premortem Tool: Facilitator Notes | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/sustainability/premortem-fac-notes.html
     December 01, 2017 - Say: Which failures would impede sustainability of the safe surgery project?

106. Research on Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/research/index.html
     March 01, 2024 - Year 2022 In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures

107. Agency for Healthcare Research and Quality Competency Check vs. Observational Audit (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/competency-check-vs-observational-audit.pdf
     March 01, 2021 - this reason, observational audits allow you to obtain accurate compliance rates and identify process failures

108. TeamSTEPPS®: National Implementation Research/Evidence Base | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/evidence-base/anesthesiology.html
     July 01, 2015 - a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures

109. Readiness Assessment | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps-program/curriculum/implement/pre/ready.html
     January 01, 2024 - If these problems are directly linked to teamwork and communication failures, they may help show the

110. Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/publications/search.html
     January 01, 2024 - experiences, explores how patient-reported experiences can augment other methods of identifying diagnostic failures

111. Selected Best Practices and Suggestions for Improvement (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4h_combo_psi11-postoprespfailure-bestpractices.pdf
     May 20, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4h Selected Best Practices and Suggestions for Improvement PSI 11: Postoperative Respiratory Failure Why Focus on Postoperative Respiratory Failure? …

112. Chapter 7. Layering Interventions and Moving Toward Excellence | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/vtguide/guide7.html
     May 01, 2016 - and correction of lapses in care. 1-7 Active surveillance techniques find ways to detect potential failures … Pharmacologic prophylaxis represents another opportunity to address failures in the VTE prevention process … relatively small proportion of patients who missed multiple doses represented the majority of administration failures

113. Toolkit for Improving Perinatal Safety | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html
     July 01, 2023 - units and decrease maternal and neonatal adverse events resulting from poor communication and system failures

114. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (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-Riley_58.pdf
     April 02, 2008 - • Team communication failures can be readily observed and documented through video. … analysis indicates that over 70 percent of sentinel events in obstetrics result from communication failures … who acknowledge receipt of information with reciprocal verbal interactions, in which there are no failures … criteria of a stable team, and training curriculums for such teams should identify specific areas of team failures … It has a number of specific training areas that can serve as effective countermeasures to the team failures

115. Selected Best Practices and Suggestions for Improvement (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4u Selected Best Practices and Suggestions for Improvement PDI 09: Postoperative Respiratory Failure Why focus on postoperative respiratory failure in chi…

116. TeamSTEPPS for Office-Based Care: Team Structure | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/officebasedcare/module2/office_structure.html
     September 01, 2015 - A wooden bucket labeled "Failures" contains many fish.

117. Hospital Deaths for Common Heart Conditions Increased While Hospitalizations Decreased During the First Year of COVID-19 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/qdr-data-spotlight-heart-failure-hospital.pdf
     July 01, 2023 - Hospital Deaths for Common Heart Conditions Increased While Hospitalizations Decreased During the First Year of COVID-19 1 Hospital Deaths for Common Heart Conditions Increased While Hospitalizations Decreased During the First Year of COVID-19 Deaths From Heart Disease Increased in 2020 Heart disease is the mo…

118. Table 4. Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-section-6-table-4.pdf
     April 30, 2018 - Table 4. Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites Table 4: Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites Site Eligibility Criteria/ Measure Numerator Number of Records R i d N Agreed (%) Kappa St…

119. Section 6. Facilitating Change and Anticipating Challenges | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/ptflow/section6.html
     July 01, 2018 - Previous failures to implement or maintain quality improvement efforts led to cynicism among some staff … addition, many staff members were skeptical about the implementation of the open-bed policy because of failures

120. Chapter 3. Care Coordination Measurement Framework | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/ncepcr/care/coordination/atlas/chapter3.html
     June 01, 2014 - a health care professional, care team, or health care organization) will be expected to answer for failures … Monitor for successes and failures in care and coordination. … Refine the care plan as needed to accommodate new information or circumstances and to address any failures