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Showing results for "failures".

1. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
   healthcare411.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
   April 01, 2021 - The tracking tool only extracts the failures in each category, so you are only required to select "NO … The tab will then automatically calculate how many “Not Met” observations or failures, were recorded … provides a high-level summary of the audit data for your facility, including and the average number of failures … (NO/Not Met) per audit, and a breakdown of where the failures are occurring by both line item (#1 - … The Summary Rates tab provides graphs outlining the average number of failures per audit and the hand

2. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
   healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
   October 01, 2023 - In general, failures in communication about changes in medication doses were common, and one in four … on preventing harm in children caused by the outpatient healthcare system, specifically identifying failures

3. Identify Defects Through Sensemaking | Agency for Healthcare Research and Quality
   healthcare411.ahrq.gov/hai/cusp/modules/identify/identify.html
   December 01, 2012 - Examples of Defects or Failures That Affect Patient Safety Slide 9. … Return to Contents   Slide 8: Examples of Defects or Failures That Affect Patient Safety Defect … Defects or failures are clinical or operational events that you do not want to happen again.

4. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
   healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
   December 01, 2022 - Catchpole’s research identified 30 potential sources of workflow failures that could be corrected with … glance; [it’s] a small intervention that may have a significant impact on reducing medication delivery failures

5. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
   healthcare411.ahrq.gov/diagnostic-safety/workgroup/index.html
   March 01, 2024 - address the lack of dedicated research into improving medical diagnosis and in particular, diagnostic failures

6. Module 5: Situation Monitoring
   healthcare411.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.  

7. Dailygoals (doc file)
   healthcare411.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

8. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
   healthcare411.ahrq.gov/patient-safety/resources/learning-lab/index.html
   February 01, 2024 - Using incident reports to assess communication failures and patient outcomes . … The PIQS Lab examined radiology imaging failures through similar conceptual lenses of shared sense making … The specific aims are to: Explore solutions to failures in diagnosis, selection, and prescribing of … Develop methods to reduce failures in the preparation, administration, and recording of intraoperative … /19-09/09/23 Description: This project addresses diagnostic errors in primary care often caused by failures

9. AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units | Agency for Healthcare Research and Quality
   healthcare411.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

10. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
    healthcare411.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.

11. Healthcare, Climate Change, Environmental Justice, and AHRQ | Agency for Healthcare Research and Quality
    healthcare411.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

12. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
    healthcare411.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

13. About the Toolkit Development | Agency for Healthcare Research and Quality
    healthcare411.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

14. I-PASS: Integrating High Quality Handoffs into TeamSTEPPS and Hospital Care
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-may2015.pptx
    January 01, 2015 - childrens.harvard.edu TEAMSTEPPS 05.2 Mod 1 05.2 Page ‹#› TeamSTEPPS® I-PASS Slide ‹#› 12 Communication Failures … Slide ‹#› 76 Results Overall, the 23 hospitals involved saw reduction in handoff related care failures … TEAMSTEPPS 05.2 Mod 1 05.2 Page ‹#› TeamSTEPPS® I-PASS Slide ‹#› 77 BCH Handoff Related Care Failures

15. Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/diagnostic-safety/index.html
    January 01, 2007 - address the lack of dedicated research into improving medical diagnosis and in particular, diagnostic failures

16. Research on Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
    healthcare411.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

17. Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/research/publications/search.html?page=0
    January 01, 2024 - experiences, explores how patient-reported experiences can augment other methods of identifying diagnostic failures

18. Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/research/publications/search.html
    January 01, 2024 - experiences, explores how patient-reported experiences can augment other methods of identifying diagnostic failures

19. Toolkit for Improving Perinatal Safety | Agency for Healthcare Research and Quality
    healthcare411.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

20. Selected Best Practices and Suggestions for Improvement (pdf file)
    healthcare411.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…