Results

Total Results: 1,922 records

Showing results for "failures".

121. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/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

122. Dailygoals (doc file)
     www.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

123. | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/tools/index.html?page=4
     October 01, 2024 - aim of decreasing maternal and neonatal adverse events resulting from poor communication and system failures

124. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
     January 01, 2024 - errors occurring in the prescribing phase of medication processing, or equipment/delivery device failures … emerged in this study and include errors that begin in the prescribing phase of medication use and failures … In addition, we found that the same types of system failures that plague inpatient medical settings … Indeed, remedying these system failures in outpatient settings is likely more complex than doing so

125. Summary of Survey Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-culture-survey-brazil-summary.html
     August 01, 2024 - Responses to the two feedback questions on failures in the diagnostic process suggested a gap in open

126. Improving Diagnosis in the Context of Rurality | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-rural-healthcare2.html
     October 01, 2024 - estimated that 33 percent  of diagnostic errors result in patient injury, 22 and 57 percent of these failures

127. Medical Failure-to-Rescue Final Report (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/silber-report.pdf
     January 01, 2025 - Medical Failure-to-Rescue Final Report Medical Failure-to-Rescue Final Report November 13, 2018 Principal Investigator: Jeffrey H. Silber, MD, PhD1,2,3,4,5 Co-investigators: Paul R. Rosenbaum, Ph.D5,6 Patrick S. Romano, MD, MPH7 Project Manager: Bijan A. Niknam, BS1 Orit Even-Shoshan, MS1,5 Senior Statis…

128. Enhancing-Care-Heart-Failure-Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/enhancing-care-heart-failure-patients.pdf
     June 02, 2025 - TAKEheart Affinity Group: Enhancing Care for Heart Failure Patients in Cardiac Rehabilitation H i c h a m S k a l i , M D , M S c S t e v e n K e t e y i a n , P h D D a n i e l F o r m a n , M D M i c h e l l e Yo u n g , M S N , A N P - B C N o v e m b e r 2 , 2 0 2 1 Welcome and Background for Tod…

129. Tool: Advocacy and Assertion | Agency for Healthcare Research and Quality
     www.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

130. Project Report - Lean Sigma (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/best_practices-slides/Best-Practices-How-Successful-Units-Engaged-Their-Senior-Exec-Leaders-Oct-18-2011-508.ppt
     January 01, 2011 - Slide * Best Practices Leadership best practices Keep senior leadership informed of progress and failures

131. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
     January 01, 2024 - Dovey and her colleagues identified administrative failures, investigation failures, treatment delivery … , even with an experienced FMEA moderator (the PI), is that the physician team needed to consider failures … We also focused on solutions that could help PCPs recover from failures, if they happened. … below, computer problems at an EHR clinic can cause patient records not to be available, accuracy failures … throughout all steps, and failures to complete steps during the present visit and at subsequent visits

132. The Comprehensive Unit-based Safety Program (CUSP) for MRSA Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp.html
     October 01, 2024 - Performing a Premortem Assessment The Premortem Tool is a proactive way to anticipate risks and failures

133. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
     January 01, 2024 - classic framework to identify and classify both latent and active errors,14 examining errors such as failures … in preventive practices that reduce adverse medication events and failures in safety monitoring for … Failures in preventive practices that are known to reduce adverse events included failures to determine … patients who plan to begin CD20-depleting therapies such as rituximab.16 Thus, we examined process failures

134. Christiana Care Health System: Safety Mentor Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell_94.pdf
     March 30, 2008 - These trends reflect our efforts to provide reliable health care by detecting failures before they occur … ) prevent failure, (2) identify and mitigate failure, and (3) redesign processes based on critical failures … Identify potential failures. … These trends reflect Christiana Care’s efforts to provide reliable health care by detecting failures

135. | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/publications/search.html?page=2
     September 01, 2023 - experiences, explores how patient-reported experiences can augment other methods of identifying diagnostic failures

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

137. Designing Consumer Reporting Systems for Patient Safety Events: Project Overview (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
     July 01, 2011 - patient safety and assist in the detection of patterns associated with medical errors or health system failures

138. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
     June 03, 2008 - most common factors contributing to adverse or “near- miss” outcomes in these cases were communication failures … The identification of potential system failures and the creation of workgroups to address specific … Identification of potential system failures by participants, empowerment of workgroups to address specific

139. TeamSTEPPS Communication - Module 1
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-1-slides.pptx
     August 03, 2022 - Communication 4 Importance of Communication Joint Commission data identify communication failures

140. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/154-performing-pre-mortem-project-assessment.pptx
     October 01, 2024 - Develop plans, strategies, and assign tasks to prevent those foreseen potential failures.