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Total Results: 237 records

Showing results for "failures".

1. Identify Defects Through Sensemaking, Facilitator Notes | Agency for Healthcare Research and Quality
   preventiveservices.ahrq.gov/hai/cusp/modules/identify/notes.html
   December 01, 2012 - Examples of Defects or Failures That Affect Patient Safety Slide 9. … Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

2. Staff Safety Assessment
   preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemaking.pptx
   January 01, 2006 - and Effects Analysis -Probabilistic Risk Assessment Tools to examine defects or failures … Learn from Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … information by residents during rounds Electronic progress note developed Examples of Defects or Failures … Sensemaking and Identifying Defects Identify defects and Sensemaking share several common themes Defects or failures

3. Did You Know, Safety Infographic (pdf file)
   preventiveservices.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
   August 01, 2021 - Did You Know, Safety Infographic Did you know... 57% of all diagnostic failures happen in ambulatory

4. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
   preventiveservices.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

5. Identify Defects Through Sensemaking | Agency for Healthcare Research and Quality
   preventiveservices.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. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
   preventiveservices.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

7. The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation (pdf file)
   preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/dx-team-assessment-scale-jtcommjqualpatsaf.pdf
   February 01, 2024 - Rosen, PhD, MA Introduction: One in three patients is affected by diagnosis-related communication failures … three patients experiences a diagnostic error firsthand and that diagnostic- related communication failures … Commis- sion, one of the most reviewed sentinel events is delay in treatment, inclusive of communication failures … assisting each other in the diagnostic process (for example, catching and correcting communication failures … Malpractice Risks in Commu- nication Failures: 2015 Annual Benchmarking Report. 2015.

8. Dailygoals (doc file)
   preventiveservices.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

9. AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units | Agency for Healthcare Research and Quality
   preventiveservices.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)
    preventiveservices.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
    preventiveservices.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. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
    preventiveservices.ahrq.gov/patient-safety/resources/learning-lab/index.html
    April 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 were to: Explore solutions to failures in diagnosis, selection, and prescribing of … Develop methods to reduce failures in the preparation, administration, and recording of intraoperative … /19-09/29/24 Description: This project addresses diagnostic errors in primary care often caused by failures

13. Research on Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
    preventiveservices.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

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

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

17. Agency for Healthcare Research and Quality
    preventiveservices.ahrq.gov/es/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
    preventiveservices.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. Heart Failure: Most Common and Expensive Reason for Preventable Hospital Stays | Agency for Healthcare Research and Quality
    preventiveservices.ahrq.gov/data/infographics/heart-failure.html
    November 01, 2020 - 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 …

20. Heart Failure Patients’ Risk of Adverse Events Higher in Poor-Performing Hospitals | Agency for Healthcare Research and Quality
    preventiveservices.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 …