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Total Results: 1,922 records

Showing results for "failures".

141. The Comprehensive Unit-based Safety Program (CUSP) for MRSA Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/surgery/cusp-mrsa-prevention.html
     April 01, 2025 - Premortem Assessment The Premortem Tool is a proactive way to anticipate risks and failures before they

142. Mini Presentation: Performing a Premortem Project Assessment
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/108-performing-premortem-project-assessment.pptx
     April 01, 2025 - Develop plans, strategies, and assign tasks to prevent those foreseen potential failures.

143. Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blike.pdf
     January 01, 2003 - test the feasibility and validity of using a human simulator to probe care systems for latent system failures … Many other latent system failures were identified (Table 2) and these findings proved to be robust and … These latent failures existed in an actual clinical unit that was providing sedation care. … team collaboration.22 This study supports the finding that, even in training exercises, latent system failures … An analysis of major errors and equipment failures in anesthesia management: considerations for prevention

144. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
     July 18, 2008 - Cognitive errors and the decisionmaking process can be seen as failures in perception, failed heuristics … decisionmaking biases, as recently popularized by Groopman in his book, How Doctors Think.11 These failures … Despite the seemingly esoteric view of cognitive failures, often problems seen in offices and clinics … Solutions must address ineffective communication, lack of teamwork principles, clinical leadership failures … Communication failures: An insidious contributor to medical mishaps.

145. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
     December 01, 2003 - Research shows that systems failures are the root cause of the majority of safety incidents. … Their understanding of the crucial role systems failures play in most patient safety incidents may be … , Professor Reason’s principal area of research has been the management of human error and systems failures … helping managers to focus on the “what” rather than the “who” and to explore ways of minimizing systems failures

146. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Johnson_90.pdf
     June 10, 2008 - part of one’s clinical practice suggests a failure to perform an appropriate analysis of the system’s failures … or to truly understand systems failures that lead to the workarounds. 6 Often, even the most … Opportunities for identifying system failures and successes, as well as how these failures and successes

147. Chapter 7. Layering Interventions and Moving Toward Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide7.html
     May 01, 2016 - and correction of lapses in care. 1-7 Active surveillance techniques find ways to detect potential failures … Pharmacologic prophylaxis represents another opportunity to address failures in the VTE prevention process … relatively small proportion of patients who missed multiple doses represented the majority of administration failures

148. Chapter 7. Layering Interventions and Moving Toward Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide7.html
     May 01, 2016 - and correction of lapses in care. 1-7 Active surveillance techniques find ways to detect potential failures … Pharmacologic prophylaxis represents another opportunity to address failures in the VTE prevention process … relatively small proportion of patients who missed multiple doses represented the majority of administration failures

149. | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/programs/index.html?page=3
     units and decrease maternal and neonatal adverse events resulting from poor communication and system failures

150. Section 6. Facilitating Change and Anticipating Challenges | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptflow/section6.html
     July 01, 2018 - Previous failures to implement or maintain quality improvement efforts led to cynicism among some staff … addition, many staff members were skeptical about the implementation of the open-bed policy because of failures

151. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
     August 01, 2022 - Further, clinical experts identified the individual, team, and system failures associated with each event … The project team noted that approximately half the failures associated with these four adverse obstetric … examined patient/family and clinician attitudes about the disclosure of individual, team, and system failures … Patients and their family members tended to agree on which failures were important to disclose, regardless … Themes and subthemes emerging from the analysis suggest failures may occur in multiple domains of the

152. Final Progress Report: Proactive Risk Assessment in the ED: Building the Safety Case (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/wears-perry-report.pdf
     January 01, 2025 - computerized status boards under normal tempo conditions, no high-risk scenarios were identified—although failures … process was based on the technique developed in the US nuclear industry to provide quantification of failures … which PRA was developed typically showed small numbers of deep trees involving multiple interacting failures … large numbers of relatively shallow trees, suggesting that, in the setting studied, single point failures … "It came from within": clinical impact of latent IT failures on patient safety.

153. Project Overview: Designing Consumer Reporting Systems for Patient Safety Events | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/consumer-exp/systems/index.html
     October 01, 2014 - patient safety and assist in the detection of patterns associated with medical errors or health system failures

154. Best Practices: How Successful Units Engaged Their Senior Executive Leaders | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/best-practices-slides/slides.html
     October 01, 2014 - Best Practices Leadership best practices: Keep senior leadership informed of progress and failures

155. Guide for Developing a Community-Based Patient Safety Advisory Council | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncil2.html
     April 01, 2018 - is a new wave of consumers who have heard stories of or actually experienced errors, mistakes, and failures

156. Final Progress Report: Multi-Method Proactive Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/pace-report.pdf
     January 01, 2024 - the intensity of service in the inpatient environment and the potential for immediately catastrophic failures … developing interventions to reduce errors and harm requires local information concerning not only system failures … Finally, we assessed failures in our care system using error reports collected during an AHRQ-funded … They were also very aware of the ongoing failures in the system, which were picked up by their tracking

157. Creating Psychological Safety in Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/psychological-safety.pdf
     June 02, 2025 - • Celebrating failures, providing positive reinforcement for innovations even though they don’t

158. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
     April 02, 2008 - • Team communication failures can be readily observed and documented through video. … analysis indicates that over 70 percent of sentinel events in obstetrics result from communication failures … who acknowledge receipt of information with reciprocal verbal interactions, in which there are no failures … criteria of a stable team, and training curriculums for such teams should identify specific areas of team failures … It has a number of specific training areas that can serve as effective countermeasures to the team failures

159. Pediatric Diagnostic Safety Research and Initiatives Across the Care Continuum | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-3.html
     August 01, 2023 - Aggregating cases with similar diagnostic process failures may allow patient safety leaders to implement … credentials across time and clinical locations may make similar reasoning errors. 86 Such predictable failures

160. Agency for Healthcare Research and Quality Competency Check vs. Observational Audit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/competency-check-vs-observational-audit.pdf
     March 01, 2021 - this reason, observational audits allow you to obtain accurate compliance rates and identify process failures