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Showing results for "failures".

201. 109-Performing-Premortem-Project-Assessment-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/109-performing-premortem-project-assessment-fg.docx
     April 01, 2025 - Develop plans and strategies to prevent those foreseen potential failures.

202. Facilitator-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/facilitator-notes.docx
     March 01, 2017 - Recognize that there will often be failures in addition to successes. … Encourage staff to find the silver linings or the pearls of wisdom in these failures.

203. An Introduction to Assessing Practices: Issues to Consider (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-12-intro-to-assessing-practices.pdf
     September 01, 2015 - review and observation as tools to conduct “fall-out” assessments, where a forensic analysis of system “failures … track patients who failed to receive their lab results within the specified time period and identify failures … The practice can use these data to correct and improve the process and reduce failures in the future

204. High-Hanging Fruit: Improving Transitions in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Perry_49.pdf
     March 27, 2008 - opportunities for reassessing situations for the explicit purpose of identifying and correcting hazards and failures … Communication failures in patient sign-out and suggestions for improvement: A critical incident analysis … Communication failures: An insidious contributor to medical mishaps.

205. Chapter 4. Developing and Pilot Testing Change: Implementing the Medication Reconciliation Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/chapter-4.html
     July 01, 2022 - method to identify design flaws and to understand underlying root causes for medication reconciliation failures

206. Chapter 4. Developing and Pilot Testing Change: Implementing the Medication Reconciliation Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-4.html
     July 01, 2022 - method to identify design flaws and to understand underlying root causes for medication reconciliation failures

207. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
     January 01, 2005 - Errors occur when latent conditions or system failures occur that are the consequences of failures in … hospital discharge is a time when accidents and adverse events happen because latent conditions or system failures … are combined with active failures. … As Moray8 and Van Cott9 point out, the prevention of active or sharp end failures requires re-engineering

208. Final Progress Report: Leveraging Existing Assessments of Risk Now (LEARN) Final Report (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
     January 01, 2025 - systematic tabular method for evaluating and documenting the causes and effects of known types of component failures … response to The Joint Commission requirement.10 In application to the healthcare environment, component failures … are replaced by process step fail-points, and an assessment of the likelihood of failures is added. … outcome/consequence). his risk information is used to identify the most significant (e.g., highest risk) failures … issues • Frequent interruptions • Number of hand-offs • Information lost or left behind • Fax failures

209. Getting Started Resource Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-resource-guide.pdf
     March 01, 2023 - November 16, 2022 9 Fishbone diagrams are a useful way to identify major causes of process failures … as well as specific failures that fall into these general categories. … team and patients in this process to ensure that you fully understand underlying causes of process failures

210. Pillars of a Smart, Safe Operating Room (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
     April 07, 2008 - Inefficiency, redundancy, communication problems, usage problems, and system failures are among the … The challenge to the health care industry is to understand and improve processes that lead to system failures … We do not have a means to show the patterns of our efficiencies or failures. … that integrates technologic components and corporate and manufacturing methodologies, so that system failures

211. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-presenters-notes.pdf
     January 12, 2022 - Estimates based on autopsy data suggest that 40,000 to 80,000 people die each year from diagnostic failures … The events in the story show how harmful communication failures can be.                                         … • Malpractice Risks in Communication Failures: 2015 CRICO Strategies National CBS Report. … 2015. https://www.rmf.harvard.edu/malpractice-data/annual-benchmark- reports/risks-in-communication-failures

212. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-introduction.pptx
     January 12, 2022 - Estimates based on autopsy data suggest that 40,000 to 80,000 people die each year from diagnostic failures … The events in the story show how harmful communication failures can be. … Malpractice Risks in Communication Failures: 2015 CRICO Strategies National CBS Report. … 2015. https://www.rmf.harvard.edu/malpractice-data/annual-benchmark-reports/risks-in-communication-failures

213. Improving the Emergency Department Discharge Process: Environmental Scan Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/edenvironmentalscan/edenvironmentalscan.pdf
     December 01, 2014 - 41 Appendix D: Past Interventions Aimed to Prevent ED Discharge Failures 42 Emergency Department … ED discharge failures have been described as follows:  ED revisits within specified timeframes (e.g … All have fairly low specificity, underscoring the difficulty in predicting discharge failures. … ED discharge failures for uninsured and underinsured patients included 72-hour returns1 (odds ratio … Appendix D: Past Interventions Aimed To Prevent ED Discharge Failures

214. Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Engleman_86.pdf
     June 04, 2008 - Potential harm to patients 5,312 Potential harm to health care provider 371 “Other” (e.g., out-of-box failures … results, inappropriate labeling, unclear instructions in labeling/ packaging, repeated quality control failures … , defective sample collection devices, and calibration failures.

215. Failure to Rescue Patient Safety Learning Lab (FTR PSLL) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/failure-rescue-long-desc.html
     April 01, 2021 - Using incident reports to assess communication failures and patient outcomes .

216. Improving Patient Safety Through Provider Communication Strategy Enhancements (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Dingley_14.pdf
     February 06, 2008 - and patient harm.1, 2, 3 A review of reports from the Joint Commission reveals that communication failures … In the acute care setting, communication failures lead to increases in patient harm, length of stay, … 13, 14, 15 1 Analysis of 421 communication events in the operating room found communication failures … Communication failures in the operating room: An observational classification of recurrent types and

217. Table A.4.1. Verisk condition classifications | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/taba.4.1.html
     December 01, 2017 - ARRA ACTION: Comparative Effectiveness of Health Care Delivery Systems for American Indians and Alaska Natives Using Enhanced Data Infrastructure Table A.4.1. Verisk condition classifications Previous Page Next Page Table of Contents ARRA ACTION: Comparative Effectiveness of Health Care Delivery Sys…

218. Final Progress Report: Inpatient-Outpatient Transitions: Reducing the Rate of Readmissions (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/jones-selna-report.pdf
     January 01, 2025 - Conclusions and Significance By systematically identifying where, how, why, and how frequently failures

219. Section 8: The Care Management Evidence Base (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm8b.html
     October 01, 2014 - Designing and Implementing Medicaid Disease and Care Management Programs Section 8: The Care Management Evidence Base (continued) Previous Page Next Page Table of Contents Designing and Implementing Medicaid Disease and Care Management Programs Introduction Section 1: Planning a Care Management …

220. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4h_combo_psi11-postoprespfailure-bestpractices.pdf
     May 20, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4h Selected Best Practices and Suggestions for Improvement PSI 11: Postoperative Respiratory Failure Why Focus on Postoperative Respiratory Failure? …