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Showing results for "failures".

2461. Faclearncusp (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/learn/faclearncusp.docx
      January 01, 2009 - SAY: The “Learn About CUSP” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit introduces CUSP and provides an overview of resources to use when applying the CUSP model. Slide 1 SAY: This module offers an outline and brief history of the CUSP model, summarizes the CUSP Toolkit modules, and expl…

2462. Assemble the Team, Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/assemble/team-notes.html
      December 01, 2012 - Assemble the Team, Facilitator Notes CUSP Toolkit The Assemble the Team module of the CUSP Toolkit addresses CUSP team composition for your quality improvement initiative.   Contents Slide 1. Cover Slide . Slide 2. Learning Objectives . Slide 3. The Unit-Based CUSP Team . Slide 4. CUSP Team Memb…

2463. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
      May 19, 2003 - Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis 323 Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis Kathleen A. Harder, John R. Bloomfield, Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush, Jamie S. Sinclair,…

2464. Final Progress Report: Acute Care Learning Laboratory - Reducing Threats to Diagnostic Fidelity in Critical Illness (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/pickering-report.pdf
      January 01, 2025 - Final Progress Report: Acute Care Learning Laboratory - Reducing Threats to Diagnostic Fidelity in Critical Illness Title of Project: Acute Care Learning Laboratory - Reducing Threats to Diagnostic Fidelity in Critical Illness Principal Investigator and Team Members: Principal Investigator: Brian Pickering, MB,…

2465. Final Progress Report: Enhanced Patient Safety Intervention to Optimize Medical (EPITOME) (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/sirio-report.pdf
      January 01, 2024 - Final Progress Report: Enhanced Patient Safety Intervention to Optimize Medical (EPITOME) Enhanced Patient Safety Intervention to Optimize Medical (EPITOME) Carl A. Sirio, MD Principal Investigator Team Members: Robert Weber, RPh, MS, Co-Investigator Wishwa Kapoor, MD, Co-Investigator Mark Roberts, MD, MRP, Co-…

2466. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
      December 01, 2017 - Sustainability: Learning From Defects: Facilitator Notes AHRQ Safety Program for Surgery Slide 1: Sustainability: Learning From Defects Say: This module will review some concepts from Learning From Defects Through Sensemaking. It will also cover the Learning From Defects process from the perspective of …

2467. Accessible Facilitator Guide: Learn From Defects for Sustainability (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
      December 01, 2017 - Accessible Facilitator Guide: Learn From Defects for Sustainability Slide Title and Commentary Slide Number and Slide Sustainability: Learning From Defects SAY: This module will review some concepts from Learning From Defects Through Sensemaking. It will also cover the Learning From Defects process from the per…

2468. Abt Single-Sided Body Template (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverviewmaterialspacket.pdf
      October 16, 2017 - Abt Single-Sided Body Template On-Time Falls Prevention: Overview Materials Packet Samples of four types of reports are provided here: • On-Time Falls High-Risk Report. • Quarterly Summary of Falls Risk Factors by Unit or Facility. • Monthly Contextual Factors Report. • Postfall Assessment Summary Report. …

2469. Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety Culture Surveys | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/urine-culture-practices-icu-transcript.html
      December 01, 2017 - from a culture of blaming individuals for errors, to one in which errors are treated not as personal failures

2470. Urine-Culture-Practices-Icu-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/urine-culture-practices-icu-transcript.docx
      January 01, 2015 - from a culture of blaming individuals for errors, to one in which errors are treated not as personal failures

2471. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
      July 01, 2023 - impact of perceived diagnostic errors.25 If we now parse out cases involving perceived diagnostic failures

2472. CHIPRA Measure 154, Section 6.B, Validity Table (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/duration/chipra-154-section-6-b-validity.pdf
      January 01, 2013 - CHIPRA Measure 154, Section 6.B, Validity Table SECTION VI. SCIENTIFIC SOUNDNESS OF THE MEASURE VI.B. Validity VI.B.1 Construct Validity To examine construct validity, we performed comparative analyses between our metrics and two existing metrics: the Continuity Ratio, also based on MAX administrative data…

2473. CHIPRA 224 Report: Anticipatory Guidance for Prevention and/or Management of Fever and Severe Infection in Children with Sickle Cell Disease (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-224-fullreport.pdf
      May 01, 2019 - CHIPRA 224 Report: Anticipatory Guidance for Prevention and/or Management of Fever and Severe Infection in Children with Sickle Cell Disease 1 Anticipatory Guidance for Prevention and/or Management of Fever and Severe Infection in Children with Sickle Cell Disease Section 1. Basic Measure Information 1.A. Me…

2474. Hemoglobin S Monitoring Prior to Chronic Transfusion Among Children With Sickle Cell Anemia (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-214-fullreport.pdf
      February 01, 2019 - Hemoglobin S Monitoring Prior to Chronic Transfusion Among Children With Sickle Cell Anemia 1 Hemoglobin S Monitoring Prior to Chronic Transfusion Among Children with Sickle Cell Anemia Section 1. Basic Measure Information 1.A. Measure Name Hemoglobin S Monitoring Prior to Chronic Transfusion Among Children wi…

2475. Anticipatory Guidance for Prevention and Management of Splenic Complications in Children with Sickle Cell Disease (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-227-fullreport.pdf
      June 01, 2019 - Anticipatory Guidance for Prevention and Management of Splenic Complications in Children with Sickle Cell Disease 1 Anticipatory Guidance for Prevention and Management of Splenic Complications in Children with Sickle Cell Disease Section 1. Basic Measure Information 1.A. Measure Name Anticipatory Guidance f…

2476. AHRQ-Funded Patient Safety Project Highlights (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-rev.pdf
      May 01, 2024 - AHRQ-Funded Patient Safety Project Highlights AHRQ-Funded Patient Safety Project Highlights Improving Healthcare Safety by Enhancing Health Information Technology and Health Information Exchange Overview Research has shown that health information technology (HIT)i and health information exchange (HIE)ii make it po…

2477. Platelet-Rich Plasma for Wound Care in the Medicare Population: Disposition of Comments (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/comments/prp-wound-care-comments.pdf
      September 01, 2020 - Platelet-Rich Plasma for Wound Care in the Medicare Population: Disposition of Comments Research Review Disposition of Comments Report Research Review Title: Platelet-Rich Plasma for Wound Care in the Medicare Population Draft report available for public comment from June 23, 2020 to July 14, 2020. Citation: Qu…

2478. Final Progress Report: TIPI Systems To Reduce Errors in Emergency Cardiac Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/selker-report.pdf
      January 01, 2024 - Final Progress Report: TIPI Systems To Reduce Errors in Emergency Cardiac Care Final Report TIPI Systems to Reduce Errors in Emergency Cardiac Care Principal Investigator: Harry P. Selker, MD, MSPH Tufts-New England Medical Center, Boston, MA Dates of Project: September 15, 2000, to August 31, 2004 Project Offi…

2479. Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/sapirstein-report.pdf
      January 01, 2025 - Final Progress Report: Transdisciplinary Learning Lab To Eliminate Patient Harm and Reduce Waste Transdisciplinary Learning Lab to Eliminate Patient Harm and Reduce Waste Johns Hopkins Medicine Principal Investigator: Adam Sapirstein, MD Project Team Members: Ravi Aron, PhD Noah Barasch, MS Howard Carolan, MBA,…

2480. AHRQ-Funded Patient Safety Project Highlights (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-rev-0724update.pdf
      July 01, 2024 - AHRQ-Funded Patient Safety Project Highlights AHRQ-Funded Patient Safety Project Highlights Improving Healthcare Safety by Enhancing Health Information Technology and Health Information Exchange Overview Research has shown that health information technology (HIT)i and health information exchange (HIE)ii make it po…