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Showing results for "failures".

21. Final Progress Report: A Pilot Study for Intrgrating Facility Information With Healthcare Information to Improve Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/anumba-report_0.pdf
    January 01, 2024 - from those failures to their effects on the healthcare delivery system. … The FTAs link the listed failures through the possible and root causes. … The Failures class documents the failures that have been recorded. … e) The costs associated with facility failures can be considerable. … The cost impacts of facility failures on the healthcare delivery process; 4.

22. Module-3-Implementation-Guide (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-implementation-guide.pdf
    June 02, 2025 - attendees will be able to: • Understand the importance of mapping key processes and identifying process failures … • Identify implementation gaps and process failures that must be addressed to support automatic … as well as specific failures that fall into these general categories. … Several specific failures prevent patients from being identified as eligible for CR. … Other failures relate to activities or beliefs of cardiologists as well as patients that are eligible

23. Chapter 2. What is Care Coordination? | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/care/coordination/atlas/chapter2.html
    June 01, 2014 - Perspectives on Care Coordination Successes and failures in care coordination will be perceived (and … and sites are met over time. 4 Patients, their families, and other informal caregivers experience failures … Patients perceive failures in terms of unreasonable levels of effort required on the part of themselves … They also perceive failures in terms of unreasonable levels of effort required on their part in order … Successes and failures in care coordination will be perceived (and may be measured) in different ways

24. Executive Summary | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
    June 01, 2023 - explores: How patient-reported experiences can augment other methods of identifying diagnostic failures … Feedback from patient experiences can be useful for addressing diagnostic failures in two distinct ways

25. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
    July 01, 2023 - Failure Mode 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 … Slide 7: Examples of Defects or Failures That Affect Patient Safety Defect Intervention … Defects or failures are clinical or operational events that you do not want to happen again.

26. Staff Safety Assessment
    www.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

27. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - Failure Mode 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 … 6 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Examples of Defects or Failures … Sensemaking and Learn From Defects Sensemaking and Learn From Defects share several common themes Defects or failures

28. Lafleur, Joanne | Agency for Healthcare Research and Quality
    www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumlafl.html
    October 01, 2014 - The grantee is interested in identifying and preventing drug-therapy failures in chronic disease populations … She is focusing on the clinical area of osteoporosis for systems interventions to prevent such failures

29. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
    September 01, 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

30. Module 3: Systems Change: Understanding Your Workflow Processes To Prepare for System Change | Agency for Healthcare Research and Quality
    www.ahrq.gov/takeheart/training/module-3/index.html
    December 01, 2022 - attendees should be able to: Understand the importance of mapping key processes and identifying process failures … Identify implementation gaps and process failures that must be addressed to support automatic referral

31. USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ppe-covid19-audit-tracking-tool-userguide.pdf
    April 01, 2021 - The tracking tool only extracts the failures in each category, so you are only required to select "NO … The tab will then automatically calculate how many “Not Met” observations or failures, were recorded … provides a high-level summary of the audit data for your facility, including and the average number of failures … (NO/Not Met) per audit, and a breakdown of where the failures are occurring by both line item and category … The Summary Rates tab provides graphs outlining the average number of failures per audit and the PPE

32. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
    April 01, 2021 - The tracking tool only extracts the failures in each category, so you are only required to select "NO … The tab will then automatically calculate how many “Not Met” observations or failures, were recorded … provides a high-level summary of the audit data for your facility, including and the average number of failures … (NO/Not Met) per audit, and a breakdown of where the failures are occurring by both line item (#1 - … The Summary Rates tab provides graphs outlining the average number of failures per audit and the hand

33. Final Progress Report: Improving ED Quality and Safety by Enhancing Operations and Quality Management (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/khare-report.pdf
    January 01, 2024 - Of the 12 high-risk failures, 58% occurred between ECG and catheterization laboratory activation. … An FMECA elicits information about any failures for each step in a process including the underlying … An FMECA also permitted ranking of failures from high to low risk. … The failures were then “binned” into high-, medium-, and low-risk bins. … To the degree possible, both hospitals tried to work on similar failures.

34. Module-3-Slides (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-slides.pdf
    February 09, 2022 - Learning Goals 6 Understand the importance of mapping key processes and identifying process failures … Identify implementation gaps and process failures that must be addressed to support automatic referral … Insights From Workflow Process Maps 22 PARTICIPANTS Use process maps to identify process gaps and failures … Use Fishbone diagrams to group failures into categories that your redesigned processes will need … Failure to refer all patients eligible for CR Patient objection to referral Referral process failures

35. Final Progress Report: Older adult safety while receiving home health services after hospital discharge (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/arbaje-report.pdf
    January 01, 2024 - Examples of the most frequent risk factors contributing to IM- related process failures were as follows … We identified numerous consequences resulting from IM-related process failures (e.g., delays in care … IM-related process failures are associated with wide- ranging consequences that can affect older adults … We identified IM-related process failures, risk factors, and outcomes that can serve as measures health … Information management goals and process failures during home visits for middle-aged and older adults

36. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide2.html
    February 01, 2016 - The focus here is on identifying barriers to improvement and failures in the current process in order … Overcoming these failures will land the team at Level 3 on the Hierarchy of Reliability, with a projected … Diagramming helps members to understand these interrelated steps and to identify where failures—or missed

37. Chapter 2. Analyze Care Delivery | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide2.html
    February 01, 2016 - The focus here is on identifying barriers to improvement and failures in the current process in order … Overcoming these failures will land the team at Level 3 on the Hierarchy of Reliability, with a projected … Diagramming helps members to understand these interrelated steps and to identify where failures—or missed

38. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
    January 01, 2004 - Unlike active failures, which are difficult to predict, latent conditions can be identified and remedied … The learning lab also identified 10 precarious events (active failures) that were the result of JACHO … Errors in health care, like human failures in any other sphere, are not just isolated causes; they are … Advances in Patient Safety: Vol. 2 430 Active failures Operative/postop complications/infections … This will result in reducing the latent conditions and active failures that lead to error.

39. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
    January 01, 2004 - Background: Reviews of recent research-related fatalities have demonstrated that clinical research system failures … : Collecting research unit-specific information on potential safety concerns could identify system failures … Typically the same system failures that might have resulted in an injury also are present in a near … However, these latent failures serve as “holes” in the usual safety mechanisms. … Other novel methods to identify and mange potential system failures in clinical research need to be

40. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
    June 01, 2023 - that 87 percent of residents recalled at least one adverse event specifically related to communication failures … frequent task switching while processing large volumes of dynamic clinical information, and both cognitive failures … and system-based failures, all of which can lead to diagnostic errors. 60 Although substantial efforts