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Showing results for "failures".

2501. Safe Medication Administration: Oxytocin | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-oxytocin.html
      July 01, 2023 - Safe Medication Administration: Oxytocin AHRQ Safety Program for Perinatal Care Purpose of the tool: This tool describes the key perinatal safety elements with examples for the safe administration of oxytocin during labor. The key elements are presented within the framework of the Comprehensive U…

2502. Best Practices in the Diagnosis and Treatment of Diverticulitis and Biliary Tract Infections (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/diverticulitis-biliary-infections-facilitator-guide.pdf
      November 01, 2019 - Best Practices in the Diagnosis and Treatment of Diverticulitis and Biliary Tract Infections AHRQ Safety Program for Improving Antibiotic Use 1 AHRQ Pub. No. 17(20)-0028-EF November 2019 Best Practices in the Diagnosis and Treatment of Diverticulitis and Biliary Tract Infections Acute…

2503. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
      May 25, 2023 - The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation The National Action Alliance to Advance Patient Safety Summer Webinar Series Robert Otto Valdez, Ph.D. Director Agency for Healthcare Research & Quality April 25, 2023 Welcome and Thank-You! Presenter Notes P…

2504. Final Progress Report: Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS) (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
      January 01, 2025 - Final Progress Report: Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS) Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS) Principal Investigator: Lusine Poghosyan, PhD, MPH, RN, FAAN, Columbia University School of Nursing Elaine M. Fle…

2505. Implement Teamwork and Communication: | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/implement/teamwork-notes.html
      December 01, 2012 - Implement Teamwork and Communication: Facilitator Notes The Implement Teamwork and Communication module of the CUSP Toolkit will help you to identify barriers to communication. Contents Slide 1. Cover Slide Slide 2. Learning Objectives Slide 3. Basic Components and Process of Communication 2 Slide 4…

2506. Safe Practices for Better Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
      April 01, 2004 - Safe Practices for Better Health Care 23 Safe Practices for Better Health Care Kenneth W. Kizer, Laura N. Blum Abstract Modern health care is highly complex, high risk, and error prone. Not surprisingly, health care errors and consequent adverse events are a leading cause of death and injury, even though wel…

2507. Improving the Value of Patient Safety Reporting Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
      June 12, 2008 - Improving the Value of Patient Safety Reporting Systems Improving the Value of Patient Safety Reporting Systems Peter J. Pronovost, MD, PhD; Laura L. Morlock, PhD; J. Bryan Sexton, PhD; Marlene R. Miller, MD, MSc; Christine G. Holzmueller, BLA; David A. Thompson, DNSc, MS; Lisa H. Lubomski, PhD; Albert W. Wu, M…

2508. Appendix B. Journal Articles Included in Literature Review | Agency for Healthcare Research and Quality
      www.ahrq.gov/data/apcd/envscan/app-b.html
      June 01, 2017 - All-Payer Claims Databases Measurement of Care: Systematic Review and Environmental Scan of Current Practices and Evidence Appendix B. Journal Articles Included in Literature Review Previous Page Next Page Table of Contents All-Payer Claims Databases Measurement of Care: Systematic Review and Enviro…

2509. Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/pfp/haccost2017.html
      November 01, 2017 - Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions Next Page Table of Contents Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions Discussion Results References …

2510. Final Progress Report: Composite Measures of Surgical Performance (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/dimick-report.pdf
      January 01, 2024 - Final Progress Report: Composite Measures of Surgical Performance Title Page Project Title: Composite Measures of Surgical Performance Principal Investigator: Justin B. Dimick, MD, MPH Team Members: John Birkmeyer, MD (Mentor) Organization: The Regents of the University of Michigan Inclusive Dates of the Project…

2511. Final Progress Report: Central Venous Catheter (CVC)–Related Bloodstream Infections in Pediatric Cancer (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/secola-report.pdf
      January 01, 2024 - Final Progress Report: Central Venous Catheter (CVC)–Related Bloodstream Infections in Pediatric Cancer 1 Central Venous Catheter (CVC)–Related Bloodstream Infections in Pediatric Cancer Principal Investigator: Rita Secola, RN, PhD, CPON Organization: University of California Los Angeles, NIHAward@research.ucla.e…

2512. Screening for Family and Intimate Partner Violence: Systematic Evidence Review (pdf file)
      www.ahrq.gov/downloads/pub/prevent/pdfser/famviolser.pdf
      March 01, 2004 - Screening for Family and Intimate Partner Violence: Systematic Evidence Review Systematic Evidence Review Number 28 Screening for Family and Intimate Partner Violence U.S. Department of Health and Human Services Agency for Healthcare Research and Quality www.ahrq.…

2513. 6. Research Gaps and Prioritization of Federally Funded HSR and PCR | Agency for Healthcare Research and Quality
      www.ahrq.gov/healthsystemsresearch/hspc-research-study/research-gaps.html
      June 01, 2020 - 6. Research Gaps and Prioritization of Federally Funded HSR and PCR Health Services and Primary Care Research Study: Comprehensive Report One of the study’s key research questions focuses on identifying research gaps—understudied or underfunded areas in HSR and PCR that, if addressed, would move the fields fo…

2514. MONAHRQ Host User Guide (pdf file)
      www.ahrq.gov/downloads/monahrq/pdf/MONAHRQV1_HostUserGuide.pdf
      May 27, 2010 - MONAHRQ Host User Guide     MONAHRQ Host User Guide Version 1.0 May 27, 2010               TABLE OF CONTENTS INTRODUCTION........................................................................................................................................... 2 …

2515. Making Healthcare Safer Practices: 13. Alarm Fatigue (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/alarm-fatigue-1.pdf
      March 01, 2020 - Making Healthcare Safer Practices: 13. Alarm Fatigue Alarm Fatigue 13-1 13. Alarm Fatigue Authors: Meghan Woo, Sc.D., and Olivia Bacon Reviewer: Ann Gaffey, R.N., M.S.N., CPHRM, DFASHRM Introduction Alarm fatigue occurs when clinicians experience high exposure to medical device alarms, causing alarm desensitiz…

2516. System Redesign Responses to Challenges in Safety-Net Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/system/systemredesignsafetynet/systemredesign.pdf
      June 01, 2015 - a process to identify where and how it might fail, and to assess the relative impact of different failures

2517. Case 5. Heights Hospital | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case5.html
      November 01, 2014 - Some failures are expected, but eventually teams will "hit a home run."

2518. Final Progress Report: Simulation Training For Rapid Assessment And Improved Teamwork (STRAIT) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/16651-Weinger-draft-1.pdf
      February 02, 2010 - Study Rationale Communication failures continue to be the most frequently cited “root cause” of adverse

2519. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
      September 03, 2014 - other teams within the facility or organization. 53 Learn From Defects Summary Defects or failures

2520. The CAHPS Ambulatory Care Improvement Guide: Determining Where to Focus Efforts to Improve Patient Experience (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/5-determining-focus/cahps-ambulatory-care-guide-section-5.pdf
      May 01, 2017 - participants’ stories often bring to life the emotional impact of excellent service as well as service failures