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Showing results for "failures".

61. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
    January 01, 2024 - errors occurring in the prescribing phase of medication processing, or equipment/delivery device failures … emerged in this study and include errors that begin in the prescribing phase of medication use and failures … In addition, we found that the same types of system failures that plague inpatient medical settings … Indeed, remedying these system failures in outpatient settings is likely more complex than doing so

62. TeamSTEPPS Research/Evidence Base: Surgical Care and OR | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps-program/evidence-base/surgical.html
    July 01, 2023 - Communication failures in the operating room: An observational classification of recurrent types and … a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures

63. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/workgroup/index.html
    April 01, 2024 - address the lack of dedicated research into improving medical diagnosis and in particular, diagnostic failures

64. TeamSTEPPS® Diagnosis Improvement: Module 5 Situation Monitoring To Improve Diagnosis - Facilitator’s Notes (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module5-presenters-notes.pdf
    January 10, 2022 - Slide 7 Where do failures occur and what role do I play? … Examples of breakdowns in communication include: • Failures in the patient accessing the healthcare … • Failures in treatments and followup.

65. Module 5: Situation Monitoring
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module5-situation-monitoring.pptx
    January 10, 2022 - the problems that arise when understanding and expectations are out of sync.    6 Slide Where do failures … Examples of breakdowns in communication include: Failures in the patient accessing the healthcare system … Failures in treatments and followup.  

66. What Exactly Is Patient Safety? (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
    July 02, 2008 - , the more resilient it is in the face of both predictable and unpredictable possible or impending failures … in the microsystem where the “sharp end” resides, where patient- caregiver interactions occur, where failures … The concept of a multilayered system, in which the failures within each of the layers must be aligned … the idea that the immediate cause of an event is almost always the end result of multiple systems failures … Knowledge from past failures might contribute to a designer’s ability to foresee potential failures

67. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/psml-planning-grants-final-report.pdf
    May 01, 2016 - About half of the identified individual, team, and system failures associated with these events were … The highest correlation in patient/family member and clinician responses was found in regard to failures … Themes and subthemes emerging from the analysis suggest failures may occur in multiple domains of the … Further, clinical experts identified the individual, team, and system failures associated with each … Themes and subthemes emerging from the analysis suggest failures may occur in multiple domains of the

68. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
    January 01, 2024 - classic framework to identify and classify both latent and active errors,14 examining errors such as failures … in preventive practices that reduce adverse medication events and failures in safety monitoring for … Failures in preventive practices that are known to reduce adverse events included failures to determine … patients who plan to begin CD20-depleting therapies such as rituximab.16 Thus, we examined process failures

69. Enhancing-Care-Heart-Failure-Patients (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/enhancing-care-heart-failure-patients.pdf
    February 13, 2023 - TAKEheart Affinity Group: Enhancing Care for Heart Failure Patients in Cardiac Rehabilitation H i c h a m S k a l i , M D , M S c S t e v e n K e t e y i a n , P h D D a n i e l F o r m a n , M D M i c h e l l e Yo u n g , M S N , A N P - B C N o v e m b e r 2 , 2 0 2 1 Welcome and Background for Tod…

70. Executive Summary | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/summary.html
    August 01, 2022 - About half of the identified individual, team, and system failures associated with these events were … care at hospital discharge accounted for a considerable proportion of malpractice claims and involved failures

71. Dailygoals (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/dailygoals.docx
    January 01, 2003 - Communication failures lead to patient harm, increased length of stay, provider dissatisfaction, and

72. AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/index.html
    July 01, 2023 - units and decrease maternal and neonatal adverse events resulting from poor communication and system failures

73. Module 3, Communication (Instructor Guide, TeamSTEPPS 2.0) (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module3/igcommunication.pdf
    October 08, 2015 - Communication Failures 8 - 9 3 mins* 4. … Communication http://www.jointcommission.org/sentinel_event.aspx Slide (OPTIONAL) COMMUNICATION FAILURES … www.jointcommission.org/sentinel_event.aspx Slide (OPTIONAL) COMMUNICATION FAILURES … Continued) OBJECTIVES TEAMSTEPPS TEAMWORK SKILLS IMPORTANCE OF COMMUNICATION (OPTIONAL) COMMUNICATION FAILURES … (OPTIONAL) COMMUNICATION FAILURES(Continued) COMMUNICATION IS… COMMUNICATION IS… (Continued) STANDARDS

74. TeamSTEPPS Research/Evidence Base: Physician/Nurse Collaboration | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps-program/evidence-base/collaboration.html
    May 01, 2023 - a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures

75. Designing Consumer Reporting Systems for Patient Safety Events: Project Overview (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
    July 01, 2011 - patient safety and assist in the detection of patterns associated with medical errors or health system failures

76. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
    April 27, 2022 - Newman- The author distinguishes between diagnostic process failures and diagnostic labeling failures … Diagnostic process failures are Toker10 problems in the diagnostic workup. … Diagnosis label failures are an incorrect diagnosis or no attempt at a diagnosis. … Preventable diagnostic error is the overlap between diagnostic process failures and diagnostic label … failures.

77. Healthcare, Climate Change, Environmental Justice, and AHRQ | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/blog/ahrqviews/healthcare-climate-change.html
    October 01, 2021 - change contributes to the heat waves, wildfires, hurricanes, droughts, flooding, and infrastructure failures

78. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
    May 01, 2016 - About half of the identified individual, team, and system failures associated with these events were … The highest correlation in patient/family member and clinician responses was found in regard to failures … Themes and subthemes emerging from the analysis suggest failures may occur in multiple domains of the … Further, clinical experts identified the individual, team, and system failures associated with each … Themes and subthemes emerging from the analysis suggest failures may occur in multiple domains of the

79. About the Toolkit Development | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
    July 01, 2023 - In addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication

80. Fallpxtool2C (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool2c.docx
    January 28, 2013 - The goal of defining a process is to hone in on patient safety vulnerabilities and potential failures