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Total Results: 1,922 records

Showing results for "failures".

181. Yale Center for Healthcare Innovation, Redesign, and Learning | Agency for Healthcare Research and Quality
     www.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

182. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
     January 01, 2024 - The FMEA team reviewed the capecitabine process map and identified potential failures at each step in … Oral chemotherapy processes Major Steps Substeps Possible Failures Causes of Failures Highest-Risk … Failures Capecitabine/Imatinib Prescribing 5 11 21 54 3 Dispensing 6 22 33 101 6 Administration

183. Facilitator Guide: Sustainability and the Premortem (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem_facnotes.docx
     December 01, 2017 - SAY: Which failures would impede sustainability of the safe surgery project?

184. Appendix E | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
     April 01, 2018 - Administration Errors 14 419  ---- Dispensing Errors 11 448  ---- Monitoring Errors and Failures

185. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stprasumm.html
     April 01, 2013 - very rare, such as the risk of SSI in the ambulatory surgery environment, and examining single-point failures

186. Final Progress Report: Risks of Inaccurate or Incomplete Preoperative Assessments in Freestanding ASCs (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/kupka-report.pdf
     January 01, 2024 - Results The most frequent and significant risks (failures) in the preoperative nursing assessment process … inventory risks, quantify the effects of risks, and prioritize actions that could prevent or mitigate failures … Developing strategies so that: a. failure can be prevented; b. the rate of failure can be reduced; or c. failures … Mechanical failures were identified as risk points for handovers.

187. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/simulation-issue-brief-references.html
     July 01, 2024 - effects analysis based on in situ simulations: a methodology to improve understanding of risks and failures

188. A Conceptual Framework for Studying the Safety of Transitions in Emergency Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Behara.pdf
     January 01, 2004 - transfer) task ignores much of what is important and does not provide insight into certain types of failures … Failures arising from interaction effects are more likely in the former, as are shared misunderstandings … Petersen’s intervention for ward cross-coverage,3 makes technological solutions to handover-related failures … These failures may be due in part to the absence of a Advances in Patient Safety: Vol. 2 320

189. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
     March 27, 2008 - wrong-site surgical and invasive procedures, while unusual,1 are the most obvious examples of systems failures … causes of NYPORTS Code 911 and Code 912 cases, listed in no specific order, included: • Communication failures … Any system can be undermined by failures of common safety behaviors.

190. Chapter 3. Risk-Informed Interventions | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpra3.html
     April 01, 2018 - , the Birnbaum measure ranks the risks based upon the relative contribution of individual component failures … process of care, and should include redundant process steps to minimize the occurrence of single-point failures

191. PowerPoint Presentation: Premortem for Sustainability
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_premortem.pptx
     December 01, 2017 - SAY: Which failures would impede sustainability of the safe surgery project?

192. Final Progress Report: Center for Safety In Emergency Care (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/wears2-report.pdf
     January 01, 2025 - epidemic of errors” to one that is more supported by safety research in other domains, that of dynamic failures … earliest, and most surprising, results was that, although transitions in care were associated with failures … The role of automation in complex system failures. Journal of Patient Safety 2005 (in press).

193. Georgia Hospitals Improve Medication Reconciliation Process With AHRQ Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/ktcquips90.html
     October 01, 2014 - ordered by the physician, which provides less opportunity for transcription errors or communication failures

194. Evidence in Use of Clinical Reasoning Checklists for Diagnostic Error Reduction (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/diagnostic-error-reduction.pdf
     September 04, 2020 - identity.2 These checklists are meant to prevent errors of execution, so-called “slips” (attention failures … ) or “lapses” (memory failures).20 Typical for these errors is that the clinician had the right plan

195. Improving the Safety of Diagnosis and Therapy in the Inpatient Setting | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
     February 01, 2024 - researchers first adapted validated tools (Safer Dx, DEER Taxonomy) to pinpoint 44 diagnostic process failures

196. Issue Brief 26: Exploration of Foundational Terminology and Paradigms for Improving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-terminology.pdf
     April 01, 2025 - found keen insights from Reason’s Swiss Cheese Model, which asserts that adverse events result from failures … Safety-I often defines factors that contribute to adverse events as failures or errors, even if it uses … to diagnose adequately and correctly may be increased by studying diagnostic successes as well as failures … Some refer to diagnostic process failures and diagnostic label failures, again emphasizing diagnosis

197. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-6.html
     June 01, 2021 - Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions

198. Half-Day Training Content | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/intro/teach/half-day.html
     August 01, 2023 - Some stories describe teamwork failures with tragic consequences.

199. OR-to-ICU Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions4.html
     June 01, 2023 - members from different disciplines, including anesthesia, surgery, and critical care. 72 Communication failures

200. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - sleep deprivation degrades residents’ cognition, alertness, and reaction time, leading to attentional failures … and significantly reduce (by more than half) the occurrence of objectively documented attentional failures … Effect of reducing interns' weekly work hours on sleep and attentional failures. … Effect of reducing interns' weekly work hours on sleep and attentional failures. … Impact of extended-duration shifts on medical errors, adverse events, and attentional failures.