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Total Results: 362 records

Showing results for "failures".

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

2. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
   pbrn.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. AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units | Agency for Healthcare Research and Quality
   pbrn.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

4. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
   pbrn.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. Identify Defects Through Sensemaking | Agency for Healthcare Research and Quality
   pbrn.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.

6. About the Toolkit Development | Agency for Healthcare Research and Quality
   pbrn.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

7. Healthcare, Climate Change, Environmental Justice, and AHRQ | Agency for Healthcare Research and Quality
   pbrn.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

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

9. Toolkit for Improving Perinatal Safety | Agency for Healthcare Research and Quality
   pbrn.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

10. Research on Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
    pbrn.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

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

12. Module 5: Situation Monitoring
    pbrn.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.  

13. Dailygoals (doc file)
    pbrn.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

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

15. Tool: Advocacy and Assertion | Agency for Healthcare Research and Quality
    pbrn.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

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

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

18. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
    June 01, 2023 - Excellence In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures

19. Yale Center for Healthcare Innovation, Redesign, and Learning | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/resources/learning-lab/yale-center-long-desc.html
    June 01, 2020 - transferred from one setting to another or one clinical team to another are at increased risk for a host of failures

20. Daily Goals Checklist | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/hai/cusp/toolkit/daily-goals.html
    December 01, 2012 - Communication failures lead to patient harm, increased length of stay, provider dissatisfaction, and