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Showing results for "failures".

101. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.html
     June 01, 2023 - That promise holds similar appeal for addressing diagnostic failures. 9 As one paper concluded, “Insights … in three broad (somewhat overlapping) categories: delays in diagnosis, missed or misdiagnosis, and failures … event occurred at all. 39 , 47 That may lead to systematic underreporting of more complex diagnostic failures

102. Final Progress Report: Reducing Risks by Engineering Resilience Into HIT for EDs (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/wears-report.pdf
     January 01, 2024 - fail, we focused instead on enhancing the ability of organizations to rapidly recover from inevitable failures … implementation phases of HIT systems; second, these are the longest-lasting phases, and the majority of failures … "It came from within": clinical impact of latent IT failures on patient safety. … The role of automation in complex system failures. Journal of Patient Safety 2005;1(1):56-61. 18.

103. Introduction on Diagnostic Documentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact2.html
     July 01, 2024 - to the final diagnosis, and can stem from multiple sources such as cognitive biases, communication failures

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

105. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - human factors engineering in understanding events and in finding remedies for the causes of system failures … these investigations— and applying human factors engineering principles to understand human and system failures … of noticing and reporting near misses is two-fold: one, it helps us to understand the causes of the failures … Rather, they moved to understand the causes of the process failures that had occurred and made the recovery … Why hospitals don’t learn from failures: Organizational and psychological dynamics that inhibit system

106. Research on Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/index.html
     November 01, 2024 - Fiscal Year 2022 In fiscal year 2022, Congress authorized funding to support AHRQ's research to address failures

107. Foundational Terminology for Diagnosis Relating to Suboptimal Processes and Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology7.html
     April 01, 2025 - Some refer to diagnostic process failures and diagnostic label failures, again emphasizing diagnosis

108. Final Progress Report: Proactive Risk Reduction in Medication Prescribing in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
     January 01, 2024 - staff from a multispecialty group practice brainstormed to create fault trees describing the system failures … Among these techniques, several are proactive and offer the opportunity to analyze the underlying failures … and refuses 6 For this component of the fault tree, the team estimated that 80% of the office failures … to engage the patient are caused by their inability to reach the patient, 5% of the these failures … events on this fault tree by establishing several working groups of clinic staff to tackle these system failures

109. Toolkit for Improving Perinatal Safety | Agency for Healthcare Research and Quality
     www.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

110. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - , the more resilient it is in the face of both predictable and unpredictable possible or impending failures … in the microsystem where the “sharp end” resides, where patient- caregiver interactions occur, where failures … The concept of a multilayered system, in which the failures within each of the layers must be aligned … the idea that the immediate cause of an event is almost always the end result of multiple systems failures … Knowledge from past failures might contribute to a designer’s ability to foresee potential failures

111. Module 5: Situation Monitoring
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-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.  

112. TeamSTEPPS® Diagnosis Improvement: Module 5 Situation Monitoring To Improve Diagnosis - Facilitator’s Notes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-presenters-notes.pdf
     January 10, 2022 - Slide 7 Where do failures occur and what role do I play? … Examples of breakdowns in communication include: • Failures in the patient accessing the healthcare … • Failures in treatments and followup.

113. Final Progress Report: Risk Assessment of Pediatric Emergency Transfers (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/holl-report.pdf
     January 01, 2025 - comprise the Pediatric Patient Safety Consortium in the Chicago area; Aim 1.1 To model potential failures … improving use of existing systems or creating new systems. • These are both common and preventable failures … With regard to faulty/unavailable equipment or resources, these failures were related to communication … Communication failures in the operating room: an observational classification of recurrent types and … Communication Failures: An Insidious Contributor to Medical Mishaps.

114. Readiness Assessment | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/implement/pre/ready.html
     January 01, 2024 - If these problems are directly linked to teamwork and communication failures, they may help show the

115. Final Progress Report: Risk Models To Improve Long-Term Care Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
     January 01, 2024 - (errors, at-risk behaviors, systems, and equipment failures) that could lead to the undesirable outcome … Undeveloped Event Undeveloped events represent a combination of failures that were not developed in the … leading to catastrophic plant or equipment failures—is evolving.27,28,29 ST-PRA is one approach to … Under each of these high-level overviews is a detailed model of the combinations of failures that will … Using Probabilistic Risk Assessment to Model Medication System Failures in Long-Term Care Facilities

116. S7: Identifying How to Improve Health Outcomes for Children in Foster Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/spotlight-s7-beal.html
     May 01, 2024 - The health risks for children in foster care are further compounded due to the frequent communication failures

117. The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-team-assessment-scale-jtcommjqualpatsaf.pdf
     June 30, 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 … role on the diag- nostic team, as facilitating teamwork among these indi- viduals is critical to avoid failures … Malpractice Risks in Commu- nication Failures: 2015 Annual Benchmarking Report. 2015.

118. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - Systemic errors are those that could be attributed to system failures—and are the most prevalent. … M&M conferences should be restructured to promote discussion and analysis of thinking failures in a … A thorough knowledge of them will provide a language for describing both thinking and affective failures

119. Chapter-2 - Failure-To-Rescue (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/failure-to-rescue-1.pdf
     March 01, 2020 - Chapter-2 - Failure-To-Rescue Failure To Rescue 2-1 2. Failure To Rescue Authors: Kendall K. Hall, M.D., M.S., Andrea Lim, and Bryan Gale, M.A. Introduction Background Failure to rescue (FTR) is failure or delay in recognizing and responding to a hospitalized patient experiencing complications from a disease p…

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