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Total Results: 598 records

Showing results for "failures".

1. Using incident reports to assess communication failures and patient outcomes. | Digital Healthcare Research
   digital.ahrq.gov/ahrq-funded-projects/effect-health-information-technology-health-care-provider-communication/citation/using
   January 01, 2023 - Using incident reports to assess communication failures and patient outcomes. … Using Incident Reports to Assess Communication Failures and Patient Outcomes.

2. Fault Tree Analysis | Digital Healthcare Research
   digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fault-tree-analysis
   January 01, 2023 - Acronym FTA Description Fault tree analyses (FTAs) study specific system, process, or product failures … ANALYZE THE TREE to understand how the causes are interrelated and think of how to prevent failures. … Pay closest attention to failures that are the most likely to happen. … Useful for modeling team-based failures.

3. Failure Mode and Effects Analysis | Digital Healthcare Research
   digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/fmea-analysis
   January 01, 2023 - Description Failure mode and effects analysis (FMEA) is a method that attempts to identify all possible failures … When examining failures. How do I use this tool? 1. ASSEMBLE A CROSS-FUNCTIONAL TEAM. … These are controls in place to prevent failures from getting to the patient. … These values will aid you when ranking the order to address potential failures. 13.

4. Murphy Diagram | Digital Healthcare Research
   digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/murphy-diagram
   January 01, 2023 - Procedure execution Uses When analyzing failures retrospectively. … If the goal of the analysis is to predict potential failures, conduct a walkthrough of the events in … Offers useful application for tasks that involve teams, as it can portray teamwork and failures alongside

5. PowerPoint Presentation (ppt file)
   digital.ahrq.gov/sites/default/files/docs/page/Dixie%20Baker1.ppt
   June 16, 2021 - Avoid/eliminate single-point failures – distributed architectures can tolerate failure more easily than … Expect failures. … application-transparent features to detect faults, failover to redundant components, and recover from infrastructure failures

6. SynergyHealth - St. Joseph's Hospital: Designing a safe hospital (pdf file)
   digital.ahrq.gov/sites/default/files/docs/page/2006Reiling_052411comp.pdf
   January 01, 2005 - Source: To Err is Human, Institute of Medicine Active Failures An error that occurs at the level … service – Minimize Handoffs – Minimize Patient Movement Design Recommendations, con’t • Active Failures … question the need for tests, treatments or meds •7% refused a test, tx or med Reduce Active Failures … Designing a safe hospital Managing the risks of organizational accidents Latent Conditions �Active Failures

7. Risk Assessment | Digital Healthcare Research
   digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/risk
   January 01, 2023 - Description Failure mode and effects analysis (FMEA) is a method that attempts to identify all possible failures … Analysis Description Fault tree analyses (FTAs) study specific system, process, or product failures

8. Manojlovich, Milisa | Digital Healthcare Research
   digital.ahrq.gov/principal-investigator/manojlovich-milisa
   January 01, 2023 - Healthcare Provider Communication Using incident reports to assess communication failures … Using Incident Reports to Assess Communication Failures and Patient Outcomes.

9. EnhanCed HandOffs (ECHO) | Digital Healthcare Research
   digital.ahrq.gov/ahrq-funded-projects/enhanced-handoffs-echo
   January 01, 2024 - interventions including checklists and processes, have been implemented across hospitals to mitigate failures … This leads to communication errors and care continuity failures. … Joanna Abraham and her team at Washington University recognize that care transition failures can lead

10. Promoting Patient Safety with Web-based Patient Profiles | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/promoting-patient-safety-web-based-patient-profiles
    January 01, 2023 - Failure Mode and Effect Analysis (FMEA) on current transitions process flows to identify potential failures … modes, possible risks, and actions to mitigate failures.

11. Cardio-HIT Phase II - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/publication/r18hs017160-kmetik-final-report-2009.pdf
    January 01, 2009 - study designed to investigate the prevalence and patterns of rates of exceptions, apparent quality failures … The calculation was performed separately on the number of measure failures and the number of exceptions … of identified failures that were true failures was within 5% of the same proportion among the entire … For these measures, quality failures would have been overestimated were reporting of exceptions not … Our finding that approximately 75% of cases considered apparent quality failures by automatic query

12. Cimino JJ et al. 2001 "Studying the human-computer-terminology interface." | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/cimino-jj-et-al-2001
    January 01, 2001 - Findings "The user interface was responsible for 3 of the 16 suboptimal results and 12 of the 66 failures … When the 30 search failures and 2 cases of extremely high results...were excluded, the average list size

13. A National Web Conference on Transitions in Care (pdf file)
    digital.ahrq.gov/sites/default/files/docs/2010-02-24%20Transitions%20In%20Care%20(4).pdf
    January 01, 2010 - Quality Rehospitalization is often a  symptom • Many rehospitalizations result from care system  failures …  in the transition from hospital to the next  source of care. • These care failures allow, and sometimes … • The failures reflect a lethal system design flaw. …   • Our aim is to fix the system to prevent these care  failures so the patient does not deteriorate … opportunity • Fragmentation of care lies behind many failed  transitions and many other system failures

14. Surveillance for Adverse Drug Events in Ambulatory Pediatrics - 2010 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/surveillance-adverse-drug-events-ambulatory-pediatrics/annual%20summary/2010
    January 01, 2010 - establish a baseline performance metric to measure improvement; 2) separate medication errors and system failures … result in harm to patients from those that do not; and 3) accurately direct interventions to prevent the failures

15. The Effect of Health Information Technology on Healthcare Provider Communication | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/effect-health-information-technology-health-care-provider-communication
    January 01, 2023 - Messaging Population: Nurse , Nurse Practitioner Using incident reports to assess communication failures … Using Incident Reports to Assess Communication Failures and Patient Outcomes.

16. Data Display and Organization | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/data-display
    January 01, 2023 - Analysis Description Fault tree analyses (FTAs) study specific system, process, or product failures

17. Artificial Intelligence and Human Factors in Healthcare Quality & Safety | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/artificial-intelligence-and-human-factors-healthcare-quality-safety
    September 30, 2024 - Process failures persist despite traditional improvement methods such as workflow analysis and root cause

18. Measuring and Improving Ambulatory Patient Safety with an Electronic Dashboard - 2012 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/measuring-and-improving-ambulatory-patient-safety-electronic-dashboard/annual-summary/2012
    January 01, 2012 - Patient safety problems, such as adverse drug events, monitoring failures, and lack of followup on abnormal

19. Information Links - Public Health and Health Information Exchanges: What’s the Value? (pdf file)
    digital.ahrq.gov/sites/default/files/docs/page/2006Mootrey_051311comp.pdf
    December 01, 2006 - identification of gaps in preventive health services • Easier identification and analysis of follow-up failures

20. Randeree E et al. 2007 "Exploring physician adoption of EMRs: a multi-case analysis." | Digital Healthcare Research
    digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/randeree-e-et-al-2007
    January 01, 2007 - The literature has documented a significant number of implementation failures by large groups and hospitals