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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. 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

6. PowerPoint Presentation (ppt file)
   digital.ahrq.gov/sites/default/files/docs/page/Dixie%20Baker1.ppt
   June 09, 2005 - 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

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. No Slide Title (ppt file)
   digital.ahrq.gov/sites/default/files/docs/implementation/REILING_8_V.ppt
   January 01, 2005 - Source: To Err is Human, Institute of Medicine Active Failures An error that occurs at the level … of 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

9. 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.

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. 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

12. 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

13. Managing Change: An Overview | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
    digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/adoption-strategies/managing-change-overview
    June 14, 2021 - This paper looks at four major areas: why information system failures occur, the core theories supporting

14. A National Web Conference on Assessing Patient Health Information Needs for Developing Consumer Health IT Tools (pdf file)
    digital.ahrq.gov/sites/default/files/docs/patient-health-information-needs-slides-050715.pdf
    May 07, 2015 - “ -Mother of children with asthma Eschler J, in submission Memory Failures “If I don’t have anything … -Mother of child with asthma Kendall L, AMIA Proceedings 2014 Reminder Tool Failures “I was freaking … Enable detection and response to reminder failures. … Reminders Traditional Reminder Tools Method 1: Home Visit Challenges from Outside the Home Memory Failures … Reminder Tool Failures Mitigating Failure Design Implications Opportunistic Reminders Method 2:

15. 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

16. Assessing the validity of national quality measures for coronary artery disease using an electronic health record | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
    digital.ahrq.gov/health-it-tools-and-resources/health-it-bibliography/quality-measurement-and-improvement/assessing
    step process of automated measurement supplemented by review of free-text notes for apparent quality failures

17. 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

18. 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

19. National Teleconference February 2011 (pdf file)
    digital.ahrq.gov/sites/default/files/docs/better-medication-management-slides-021611.pdf
    February 16, 2011 - BMJ. 2000 Mar 18;320(7237):768-70 System Failures • Human fallibility is only part of the … problem • Failures at the system level – in disseminating pharmaceutical information – in checking … into the construction of the risk models for each high-alert medication • Quantified the risk of failures … prepared in case of a technology failure. 6 P Recovery and back up plans associated with technology failures … The Road to Safer Patient Care: Leveraging IT Approach to Errors System Failures Injuries are not

20. Evidence for electronic health record systems in physical therapy | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency
    digital.ahrq.gov/health-it-tools-and-resources/health-it-costs-and-benefits-database/evidence-electronic-health
    March 01, 2006 - In the early system which used a mainframe computer, system failures frustrated users and led to required