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Total Results: 1,922 records

Showing results for "failures".

301. 136-Ss-Premortem-Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/136-ss-premortem-tool.docx
     April 01, 2025 - Comprehensive Unit-based Safety Program (CUSP) Premortem Project Assessment Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Projects often fail, and many factors may contribute to this failure. Understanding potential implementation barriers and challenges before launching a …

302. Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/King.pdf
     January 01, 2002 - two needs assessments, where closed claims were reviewed for the presence or absence of teamwork failures … in place to sustain continued success, it is important to examine successful initiatives as well as failures

303. Assess and Adapt: Understanding the Science of Safety and Reliability | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-slides.html
     July 01, 2018 - Slide 17 System Failures Leading to Error (Reason, 1990) Image: Four chunks of swiss cheese with

304. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology1.html
     April 01, 2025 - Exploration of Foundational Terminology and Paradigms for Improving Diagnosis Introduction Previous Page Next Page Table of Contents Exploration of Foundational Terminology and Paradigms for Improving Diagnosis Introduction Perspectives on Diagnostic Improvement Definitions of Diagnosis Type…

305. Implementation Guide for Automatic Referral: Building, Implementing, and Troubleshooting and Automatic Referral for Cardiac Rehabilitation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/implementing-automatic-referral-implementation-guide.pdf
     March 01, 2023 - . • Review the referral process failures identified during your mapping exercise. • Build a referral

306. Webinar 2: Analyze Data and Patient/Caregiver Perspectives (Section 1 of the Guide): Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/guide/web2.html
     December 01, 2017 - Webinar 2: Analyze Data and Patient/Caregiver Perspectives (Section 1 of the Guide): Slide Presentation Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions Text version of Webinar slide presentation. Slide 1: Designing & Delivering Whole-Person Transit…

307. 116-Cusp-Premortem-Project-Assessment (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/116-cusp-premortem-project-assessment.docx
     January 01, 2007 - AHRQ Safety Program for MRSA Prevention Comprehensive Unit-based Safety Program (CUSP) Premortem Project Assessment ICU & Non-ICU Projects often fail, and many factors may contribute to this failure. Understanding potential implementation barriers and challenges before launching a project can help the team mitigate the…

308. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
     April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Exhibit 9. Top five minimal cut sets for the basic case Previous Page Next Page Table of Contents Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Executive Summary Chapter 1. Int…

309. Implementing Shared Decision-Making: Barriers and Solutions—An Orthopedic Case Study | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/mincer.html
     August 01, 2017 - As communication failures between patients and health care providers are at the root of systems’ failures … Identifying and addressing communication failures as a means of reducing unnecessary malpractice claims

310. Usability Testing and the Relation of Clinical Information Systems to Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Rogers.pdf
     January 01, 2003 - mismatches between systems design and the structure of work create the potential for new paths to system failures … usability testing focuses attention on specific aspects of the interface to identify pitfalls and system failures … We were able to identify new paths to failures using this method and recommended the software to simplify

311. Observing Nurse Interaction with Infusion Pump Technologies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
     January 01, 2004 - interruptions in the process, patient and nurse comments, nurse interaction with technology, technology failures … medication administration starts; duration of the observation; and automation surprises/technology failures … as well as the nurse’s reaction to these automation surprises and technology failures.

312. Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Zhang.pdf
     January 01, 2004 - Most of these errors are due to inappropriate designs for user interactions, rather than mechanical failures … suggests that injuries resulting from medical device use errors far exceed injuries arising from device failures … Most of these errors are due to inappropriate designs for user interactions, rather than mechanical failures

313. Table 16A: Outcome Indicators by County Socioeconomic Status | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
     December 01, 2012 - Assessing the Health and Welfare of the HCBS Population Table 16A: Outcome Indicators by County Socioeconomic Status Previous Page Next Page Table of Contents Assessing the Health and Welfare of the HCBS Population Introduction HCBS Population Availability and Use of State Medicaid HCBS Outc…

314. Fundamental Concepts for Understanding Probability | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking2.html
     September 01, 2022 - Improved Diagnostic Accuracy Through Probability-Based Diagnosis Fundamental Concepts for Understanding Probability Previous Page Next Page Table of Contents Improved Diagnostic Accuracy Through Probability-Based Diagnosis Introduction Fundamental Concepts for Understanding Probability Probabi…

315. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
     January 01, 2017 - Presentation: Program Overview Early Mobility in the Intensive Care Unit AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-15-EF January 2017 Early Mobility in the ICU ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Objectives After this session, you will…

316. Table 7: Prevalence of selected health conditions among adults by diabetes status. All project sites. Fiscal year 2010. | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap5tab7.html
     December 01, 2017 - Table 7: Prevalence of selected health conditions among adults by diabetes status. All project sites. Fiscal year 2010. ARRA Grants Initiative Findings from a set of 16 grants on improving delivery systems and on spreading evidence-based practices through delivery systems; recommendations and methods for adva…

317. Exhibit 13. Probability of intervention reducing risk of surgical site infection (SSI) by multiple concurrent interventions at various reductions of noncompliance rates (25, 5 | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/stpra/stpraexh13.html
     April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers Exhibit 13. Probability of intervention reducing risk of surgical site infection (SSI) by multiple concurrent interventions at various reductions of noncompliance rates (25, 5 Previous Page Next Page Table of Contents …

318. Final Progress Report: The Value of Hospital-Related Patient-Safety Interventions to Key Stakeholders (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/nuckols-report.pdf
     January 01, 2024 - Identifying market failures, such as a lack of a business case from the hospital perspective, or a lack … from the implementation of an intervention, subsidies are one logical option for resolving market failures

319. Final Progress Report: Patient Advocacy Summit: Patients at the Center of Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/earp-report.pdf
     January 01, 2024 - enormous costs borne by patients, caregivers, providers, and society as whole as a result of these system failures … costs borne by patients, caregivers, providers, and society as whole as a result of these system failures

320. 0129Table8 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129table8.pdf
     January 01, 2013 - Table 8 – Evidence for the Relationship between Readmission and Quality of Care Type of Evidence Key Findings Citation Readmission and Quality of Care Coordination, Discharge, and Care Transition Processes Meta-analysis Investigators reviewed randomized controlled studies of structured telephone support or t…