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Showing results for "failures".

21. Executive Summary | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
    June 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

22. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
    January 01, 2004 - Unlike active failures, which are difficult to predict, latent conditions can be identified and remedied … The learning lab also identified 10 precarious events (active failures) that were the result of JACHO … Errors in health care, like human failures in any other sphere, are not just isolated causes; they are … Advances in Patient Safety: Vol. 2 430 Active failures Operative/postop complications/infections … This will result in reducing the latent conditions and active failures that lead to error.

23. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
    January 01, 2004 - Background: Reviews of recent research-related fatalities have demonstrated that clinical research system failures … : Collecting research unit-specific information on potential safety concerns could identify system failures … Typically the same system failures that might have resulted in an injury also are present in a near … However, these latent failures serve as “holes” in the usual safety mechanisms. … Other novel methods to identify and mange potential system failures in clinical research need to be

24. Impact of Pharmacy-led Dyslipidemia Interventions on Medication Safety and Therapeutic Failure in Patients (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weaver.pdf
    January 01, 2003 - Results demonstrated significant improvements in LDL values among patients with previous therapeutic failures … Failures requiring atorvastatin as an alternate agent were defined as (a) patients not at their LDL … Category 4 incorporates treatment selection according to PEC guidelines on therapeutic failures. … Comparison of barrier analysis for therapeutic failures Acknowledgments The authors would like … Comparison of barrier analysis for therapeutic failures << /ASCII85EncodePages false

25. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
    June 01, 2023 - that 87 percent of residents recalled at least one adverse event specifically related to communication failures … frequent task switching while processing large volumes of dynamic clinical information, and both cognitive failures … and system-based failures, all of which can lead to diagnostic errors. 60 Although substantial efforts

26. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
    July 01, 2023 - 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 … Slide 7: Examples of Defects or Failures That Affect Patient Safety Defect Intervention Medication … Defects or failures are clinical or operational events that you do not want to happen again.

27. Module 3: Systems Change: Understanding Your Workflow Processes To Prepare for System Change | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/takeheart/training/module-3/index.html
    December 01, 2022 - attendees should be able to: Understand the importance of mapping key processes and identifying process failures … Identify implementation gaps and process failures that must be addressed to support automatic referral

28. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
    September 01, 2020 - identity. 2 These checklists are meant to prevent errors of execution, so-called “slips” (attention failures … ) or “lapses” (memory failures). 20 Typical for these errors is that the clinician had the right plan

29. 5 Tk2 P3T2-Sample Procedures Phase 3 (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.doc
    January 01, 1999 - The use of antibiograms can help reduce inappropriate prescribing and lead to fewer clinical failures

30. Module-5-Slides (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-slides.pdf
    December 31, 2022 - Leaping  Changing and redesigning CR workflow processes to overcome your current problems and process failures … important  How you implemented AR  Key advice for peers just starting the process Causes of Failures … set, notify the CR program, a combination of approaches) the referral should be made These are the failures … bother Implicit biases excluded from automated referral How Automatic Referral Addresses Process Failures

31. 5 Tk2 P3T2-Sample Procedures Phase 3 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.pdf
    May 01, 2014 - The use of antibiograms can help reduce inappropriate prescribing and lead to fewer clinical failures

32. 5 Tk2 P3T1-Sample Policy Phase 3 (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T1-Sample_Policy_Phase_3.doc
    May 01, 2014 - helps reduce reliance on broad-spectrum antibiotics as initial therapy and leads to fewer clinical failures

33. Part Four: A Research Agenda To Advance the Science of Physician Feedback Reporting Systems | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/ncepcr/tools/confid-report/research-agenda.html
    March 01, 2016 - Identify implementation failures ( Grimshaw, 2015 ). … As much can be learned from implementation failures as from successes yet null findings on any topic … To better enable the identification of failures, efforts to more systematically identify and centrally

34. Findings | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
    August 01, 2022 - examined patient, family, and clinician attitudes about the disclosure of individual, team, and system failures … group and survey data revealed that patients and their family members tended to agree on which system failures … The highest correlation in patient/family member and clinician responses was found in regard to failures … researchers collected and reviewed the hospital’s clinical and administrative documents to identify potential failures … Themes and subthemes emerging from the analysis suggest failures may occur in multiple domains of the

35. 5 Tk2 P3T1-Sample Policy Phase 3 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T1-Sample_Policy_Phase_3.pdf
    May 01, 2014 - helps reduce reliance on broad-spectrum antibiotics as initial therapy and leads to fewer clinical failures

36. Barriers Associated with Medication Information Handoffs (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
    January 01, 2004 - The group brainstormed both failures and their effects. … Failures associated with medication information transfer The major failures associated with medication … Admission failures include omitted medications, altered doses, or missed allergies. … Several of the failures emerging from the FMEA were corroborated via chart review. … Many failures, such as those associated with illegibility, miscommunication, and limited information

37. 5 Tk2 P1T4-Antibiogram Factsheet Phase 1 (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P1T4-Antibiogram_Factsheet_Phase_1.doc
    January 01, 2014 - reduced reliance on broad-spectrum antibiotics as initial therapy and can result in fewer clinical failures

38. 5 Tk2 P3T3-Antibiogram Factsheet Phase 3 (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T3-Antibiogram_Factsheet_Phase_3.doc
    January 01, 2014 - reduced reliance on broad-spectrum antibiotics as initial therapy and can result in fewer clinical failures

39. Did You Know, Safety Infographic (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
    August 01, 2021 - Did You Know, Safety Infographic Did you know... 57% of all diagnostic failures happen in ambulatory

40. Appendix A. Atlas Perspective and Domain Definitions | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/pcpaccountability/pcpaccapa.html
    July 01, 2018 - 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