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Total Results: 253 records

Showing results for "failures".

1. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
   patientregistry.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
   patientregistry.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. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
   patientregistry.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

4. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
   patientregistry.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

5. Module 5: Situation Monitoring
   patientregistry.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.  

6. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
   patientregistry.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

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

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

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

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

11. Agency for Healthcare Research and Quality
    patientregistry.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

12. Toolkit for Improving Perinatal Safety | Agency for Healthcare Research and Quality
    patientregistry.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

13. Selected Best Practices and Suggestions for Improvement (pdf file)
    patientregistry.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…

14. Hospital Deaths for Common Heart Conditions Increased While Hospitalizations Decreased During the First Year of COVID-19 (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/qdr-data-spotlight-heart-failure-hospital.pdf
    July 01, 2023 - Hospital Deaths for Common Heart Conditions Increased While Hospitalizations Decreased During the First Year of COVID-19 1 Hospital Deaths for Common Heart Conditions Increased While Hospitalizations Decreased During the First Year of COVID-19 Deaths From Heart Disease Increased in 2020 Heart disease is the mo…

15. TeamSTEPPS Fundamentals Course: Module 3. Communication | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
    March 01, 2019 - Communication Failures 8—9 3 mins * 4. … Objectives TeamSTEPPS Teamwork Skills Importance of Communication (Optional) Communication Failures … Return to Contents (Optional) Communication Failures Instructor Note: Create a slide showing your

16. Tool: Advocacy and Assertion | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/teamstepps-program/curriculum/mutual/tools/advocacy.html
    June 01, 2023 - hierarchical, such as healthcare, the military, and commercial aviation, have all experienced tragic failures

17. Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/tools/index.html?page=3
    September 01, 2012 - aim of decreasing maternal and neonatal adverse events resulting from poor communication and system failures

18. Strategy 6P: Service Recovery Programs | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6p-service-recovery.html
    April 01, 2022 - If you make it hard for members or patients to complain, you will continue to miss important service failures … Use this team to develop planned protocols for service recovery for your most common service failures

19. Final Topic Refinement Document: Home Mechanical Ventilators (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
    October 01, 2017 - Final Topic Refinement Document: Home Mechanical Ventilators Final Topic Refinement Document Home Mechanical Ventilators ID: PULT0717 Agency for Healthcare Research and Quality Technology Assessment Program Mayo Clinic Evidence-based Practice Center 16 October 2017 Preliminary Key Questions (KQs) …

20. Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing Hospitals | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/news/newsletters/e-newsletter/899.html
    February 01, 2024 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …