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Total Results: 1,922 records

Showing results for "failures".

241. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/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

242. Part 2: Trends in Priorities of the Heckler Report—Care for Cardiovascular Diseases | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part2-cvd.html
     May 01, 2018 - Chartbook for Hispanic Health Care Part 2: Trends in Priorities of the Heckler Report—Care for Cardiovascular Diseases Previous Page Next Page Table of Contents Chartbook for Hispanic Health Care Acknowledgments Health Care For Hispanics National Quality Strategy Priorities: Patient Safety N…

243. Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation Challenge Grant (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/jack-report.pdf
     January 01, 2024 - with monthly input from the advisory group) studied the process map and developed a list of potential failures … It also helped identify and confirm in a very tangible way the specific failures of the hospital discharge

244. Final Progress Report: Benchmarking Patient Safety and Quality in U.S. Hospitals: The Stochastic Frontier Approach (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/unruh-report.pdf
     January 01, 2025 - Final Progress Report: Benchmarking Patient Safety and Quality in U.S. Hospitals: The Stochastic Frontier Approach Title of Grant: Benchmarking Patient Safety and Quality in U.S. Hospitals: The Stochastic Frontier Approach Principal Investigator: Lynn Unruh, PhD, RN, LHRM, Department of Health Management & Inf…

245. AHRQ Grant Final Progress Report: Improving Patient Safety Through Provider Communication Strategy Enhancements (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/daugherty-report.pdf
     January 01, 2024 - the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reveal that communication failures … In the acute care setting, communication failures lead to increased patient harm, length of stay, and … communication in the operating room, analyzing 421 communication events, and found that communication failures … Communication failures in the operating room: an observational classification of recurrent types and

246. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/index.html
     August 01, 2025 - Using incident reports to assess communication failures and patient outcomes . … The PIQS Lab examined radiology imaging failures through similar conceptual lenses of shared sense making … The specific aims were to: Explore solutions to failures in diagnosis, selection, and prescribing of … Develop methods to reduce failures in the preparation, administration, and recording of intraoperative … /19-09/29/24 Description: This project addressed diagnostic errors in primary care often caused by failures

247. Tool: Premortem (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/premortem-tool.docx
     January 01, 2017 - Tool: Premortem 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 project implementation and success BEFORE the launch of a new program can miti…

248. Data Reveal Uneven Impact of COVID-19 on Urban, Rural Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/913.html
     May 01, 2024 - Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal

249. Welcome Guide for Patients and Family Caregivers | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/welcome-guides/caregivers.html
     July 01, 2023 - While reflecting on patient harms that resulted from systemic and teamwork failures can have value, consider

250. Welcome Guide for Experienced Trainers | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/welcome-guides/experienced-trainers.html
     July 01, 2023 - While reflecting on patient harms that resulted from systemic and teamwork failures can have value, consider

251. Situation Monitoring: Obstetric Hemorrhage - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_4-situation-monitoring.pptx
     July 01, 2023 - weaknesses in the system (Reporting & Systems Learning) E.g., inefficient work processes; technology failures … Examples of system issues include technology failures, such as alarms that are easily turned off; environmental … Debriefs are not opportunities for venting personal grievances or blaming individual team members for failures … families, and staff  Debrief regularly to establish a culture of continuous learning from successes and failures

252. Getting Started: Laying the Groundwork for Implementing Automatic Referral and Effective Care Coordination (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-implementation-guide.pdf
     March 01, 2023 - that are working well and that should be replicated • Work as a team to identify workflow process failures … • Use a fishbone diagram [below] to categorize process failures that need to be addressed. … your team and patients in this process to ensure a full understanding of underlying causes of process failures … In the sample fishbone diagram below, several specific failures prevent patients from being identified

253. Part 2: Trends in Priorities of the Heckler Report—Care for Cardiovascular Diseases | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part2-cvd.html
     June 01, 2018 - Chartbook on Health Care for Blacks Part 2: Trends in Priorities of the Heckler Report—Care for Cardiovascular Diseases Previous Page Next Page Table of Contents Chartbook on Health Care for Blacks Health Care for Blacks Acknowledgments Part 1: Overviews of the Report and the Black Population …

254. Using Home Visits to Understand Medication Errors in Children (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Walsh_74.pdf
     May 28, 2008 - Themes are grouped in broad categories that reflect types of medication delivery system failures (e.g … provides space for a detailed description of the incident, including information about any systems failures … Additional sections support this description, by naming the system failures that occurred and possible … These methods may be used to develop and test interventions to prevent systems failures associated with

255. Specific Tools To Support Change (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/g2_pdi_specifictoolstosupportchange.pdf
     January 01, 2011 - a process to identify where and how it might fail and to assess the relative impact of different failures … It presents the thoughts, successes, and failures of hospital leaders who have used concepts of high … Creating an organizational culture and set of work processes that reduce system failures and effectively … respond when failures do occur is the goal of high reliability thinking.

256. Specific Tools To Support Change (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/g2_combo_specifictoolstosupportchange.pdf
     January 01, 2011 - a process to identify where and how it might fail and to assess the relative impact of different failures … It presents the thoughts, successes, and failures of hospital leaders who have used concepts of high … Creating an organizational culture and set of work processes that reduce system failures and effectively … respond when failures do occur is the goal of high reliability thinking.

257. A Process-centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Akins.pdf
     January 01, 2003 - targeted individuals and centered on training, rules, and sanctions rather than on systems and system failures … He distinguished between active failures as unsafe acts of omission or commission and latent failures … Thus, latent failures provide the work conditions where unsafe acts occur.

258. Transitions of Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html
     June 01, 2018 - Chartbook on Care Coordination Transitions of Care Previous Page Next Page Table of Contents Chartbook on Care Coordination Acknowledgments Care Coordination Trends in Care Coordination Measures Transitions of Care Preventable Emergency Department Visits Potentially Avoidable Hospitaliza…

259. Final Topic Refinement Document: Home Mechanical Ventilators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/home-mechanical-ventilators-refinement.pdf
     October 01, 2017 - Final Topic Refinement Document: Home Mechanical Ventilators Final Topic Refinement Document Home Mechanical Ventilators ID: PULT0717 Agency for Healthcare Research and Quality Technology Assessment Program Mayo Clinic Evidence-based Practice Center 16 October 2017 Preliminary Key Questions (KQs) …

260. Error Producing Conditions in the Intensive Care Unit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - Reason distinguishes between two elements present in cases of human error: active failures and latent … Active failures can refer to several different types of actions: • Action slips—for example, selecting … Organizational-historical analysis of the “failures to respond to alarm” problem.