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Showing results for "failures".

221. Table 4. Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-section-6-table-4.pdf
     June 02, 2025 - Table 4. Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites Table 4: Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites Site Eligibility Criteria/ Measure Numerator Number of Records R i d N Agreed (%) Kappa St…

222. Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-woods_79.pdf
     May 30, 2008 - In the adapted LEARN Safety Analysis methodology, after “risk binning” the failures, representative

223. Engineering Safe Practices Affinity Group | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/engineering-safety-practice/index.html
     April 01, 2025 - Establish standard contingency plans for high-risk failures such as cybersecurity breaches, natural disasters

224. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 2016 - Selected Best Practices and Suggestions for Improvement Pediatric Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4g Selected Best Practices and Suggestions for Improvement PDI 09: Postoperative Respiratory Failure Why focus on postoperative respiratory fail…

225. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 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.4u Selected Best Practices and Suggestions for Improvement PDI 09: Postoperative Respiratory Failure Why focus on postoperative respiratory failure in chi…

226. Premortem Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/premortem-tool.html
     January 01, 2017 - Premortem Tool AHRQ Safety Program for Mechanically Ventilated Patients Problem Statement Projects often fail due to many circumstances. Quality improvement programs, like the Comprehensive Unit-based Safety Program (CUSP) are no exception. Understanding potential barriers and complications to…

227. Final Progress Report: Risk and Recovery in Complex Environments: Labor and Delivery as a Model (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/goldman2-report.pdf
     January 01, 2025 - usability/misuse issues  failure definitions for components and processes  effects of specific component failures … The scenarios that we generated are comprehensive in terms of depicting the dependencies among failures

228. Hospital Deaths for Common Heart Conditions Increased While Hospitalizations Decreased During the First Year of COVID-19 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/qdr-data-spotlight-heart-failure-hospital.pdf
     July 01, 2023 - Hospital Deaths for Common Heart Conditions Increased While Hospitalizations Decreased During the First Year of COVID-19 1 Hospital Deaths for Common Heart Conditions Increased While Hospitalizations Decreased During the First Year of COVID-19 Deaths From Heart Disease Increased in 2020 Heart disease is the mo…

229. RED Lowering Hospital Readmissions and Improving Patient Satisfaction at Euclid Hospital in Ohio | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201415.html
     September 01, 2014 - RED Lowering Hospital Readmissions and Improving Patient Satisfaction at Euclid Hospital in Ohio Search All Impact Case Studies September 2014 Two years after introducing AHRQ's Re-Engineered Discharge (RED) toolkit and seeing patient satisfaction improve and avoidable heart failure readmissions decrease,…

230. Final Progress Report: Probabilistic Risk Assessment Chicago Transplant Inquiry Study (PRACTIS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/cook-report.pdf
     January 01, 2024 - the system to have the features that the model contains and that creates the opportunities for the failures

231. Making Effective Behavior Changes Around Antibiotic Prescribing (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-facilitator-guide.pdf
     November 01, 2019 - Slide 17 Stewardship Team Communication Failures SAY: Some common stewardship team communication … failures include:  Recommendations are too complex  Sounding doubtful  Sounding accusatory

232. Final Progress Report: Ambulatory Pediatric Patient Safety Learning Lab: Pursuing Safe Healthcare at Home (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/walsh-kirkendall-report.pdf
     January 01, 2025 - prescribed and managed by developmental pediatricians, with referrals to mental health after repeated failures … with parents and clinic staff were employed to deliver a comprehensive understanding of potential failures … partnership with a APRN and RN, a separate FMEA was conducted that focused on communication (and potential failures … Two others were repeated failures to administer insulin at home properly. … Highest-risk failures identified by eight parents and four clinic staff in separate failure modes and

233. TeamSTEPPS® Diagnosis Improvement: Team Assessment Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-team-assessment-tool.pdf
     February 01, 2022 - proactively assisting each other in the diagnostic process (e.g., catching and correcting communication failures

234. A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
     June 11, 2003 - The new reporting system is used to assess systems failures, not individual performance. … The staff was reassured that the new Culture of Safety program was assessing systems failures.

235. TeamSTEPPS for Improving Diagnosis Participant Workbook (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-particpant-workbook.pdf
     February 04, 2022 - Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. … rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … patients experiences a diagnostic error firsthand.11 in 3 Diagnostic-related communication failures … 2012.pdf https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures

236. Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/moyer-report.pdf
     January 01, 2024 - Final Progress Report: Crossing an Invisible Quality Chasm: From NICU to Ambulatory Care AHRQ Grant Final Progress Report Title: Crossing An Invisible Quality Chasm: From NICU to Ambulatory Care Principal Investigator: Virginia A. Moyer, MD, MPH Team Members: Papile, Lucille A., MD, Co-Investigator Guillory, Char…

237. Science of Safety and Identifying Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
     February 01, 2017 - Once these systems are understood, staff will be able to effectively identify system failures that can

238. I. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/crctoolkit/crctoolkit1.html
     April 01, 2018 - Finally, since "failures to inform patients or to document informing patients of abnormal outpatient

239. Heart Failure: Most Common and Expensive Reason for Preventable Hospital Stays | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/heart-failure.html
     November 01, 2020 - Heart Failure: Most Common and Expensive Reason for Preventable Hospital Stays Heart Failure: Most Common and Expensive Reason for Preventable Hospital Stays (PDF, 1.7 MB)   Source: HCUP Statistical Brief #259, Characteristics and Costs of Potentially Preventable Inpatient Stays, 2017 (PDF, 268 KB). V…

240. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
     www.ahrq.gov/downloads/pub/advances/vol2/Schiff.pdf
     January 01, 2005 - The taxonomy identifies where in the diagnostic process the failures occur. … understand where and how diagnosis fails and explore ways to target interventions that might prevent such failures … spotlight of patient safety, this aspect of clinical medicine is clearly vulnerable to well-documented failures … Critical information can be missed because of failures in history-taking, lack of access to medical … records, failures in the transmission of diagnostic test results, or faulty records organization (either