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Showing results for "failures".

  1. www.ahrq.gov/news/newsroom/case-studies/201507.html
    April 01, 2015 - Memorial Hospital Uses AHRQ Resources to Cut Readmissions, Promote Patient Self-Management Search All Impact Case Studies April 2015 Memorial Hospital, a 97-bed community hospital in Marysville, Ohio, uses strategies from AHRQ's Re-Engineered Discharge (RED) toolkit to help newly discharged patients follo…
  2. www.ahrq.gov/sites/default/files/2024-04/ratliff-report.pdf
    January 01, 2024 - Final Progress Report: Developing a patient-centered model of the risk of perioperative complications in spine surgery Developing a patient-centered model of the risk of perioperative complications in spine surgery John Ratliff, MD, PI Team members: Summer Han, PhD Richard Olshen, PhD Lu Tian, PhD Paola Suarez …
  3. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-19.html
    November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies Exhibit 4.19. Major Factors that Inhibit Lean Success Previous Page Next Page Table of Contents Improving Care Delivery Through Lean: Implementation Case Studies Introduction to the Case Studies Case 1. Lakeview Healthcare Case …
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-slides.pptx
    January 01, 2017 - Presentation: Tools for Sustainability: Premortem and Scorecard Tools for Sustainability: Premortem and Scorecard AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-39-EF January 2017 Sustainability Tools ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Ob…
  5. www.ahrq.gov/sites/default/files/2024-01/minnitti-report.pdf
    January 01, 2024 - Participants were asked to analyze each step, identifying potential failures. … Although the FMEA did not yield a ranking of the key risks, the groups did identify failures that could … As they identified those potential failures, they began to share ideas for how to prevent or mitigate
  6. www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool-30day.html
    March 01, 2013 - Re-Engineered Discharge (RED) Toolkit How CMS Measures the "30-Day All Cause Rehospitalization Rate" on the Hospital Compare Web Site Previous Page Next Page Table of Contents Re-Engineered Discharge (RED) Toolkit Tool 1: Overview Tool 2: How To Begin the Re-engineered Discharge Implementation a…
  7. www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool-30day.html
    March 01, 2013 - Re-Engineered Discharge (RED) Toolkit How CMS Measures the "30-Day All Cause Rehospitalization Rate" on the Hospital Compare Web Site Previous Page Next Page Table of Contents Re-Engineered Discharge (RED) Toolkit Tool 1: Overview Tool 2: How To Begin the Re-engineered Discharge Implementation a…
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
    January 20, 2008 - “Active failures” are unsafe acts committed by people who are in direct contact with the patient … “Latent conditions” are the inevitable systems failures, that relate to design—such as alarms that
  9. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/sppcii-module-handouts.docx
    July 01, 2023 - Implementation Module Handouts Implementation Module Handouts Use these handouts to help your team implement the Safety Program in Perinatal Care. For each tool, follow the actions listed to develop information to fill in the tables. Hospital AIM Team Staff List Actions: Select members for a multidisciplinary Hospit…
  10. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14.html
    February 01, 2023 - Assessing the Health and Welfare of the HCBS Population Table 14A: Outcome Indicators by County Supply of Health Care Providers 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 …
  11. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-2.html
    June 01, 2020 - Measurement should not be used punitively to identify provider failures but rather should be used to
  12. www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap5tab22.html
    December 01, 2017 - Table 22. Indian Health Service total treatment cost estimates a by health 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 advan…
  13. Slide 1 (ppt file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/hopkinsinternalmed-slides.ppt
    January 01, 2013 - Slide 1 Algorithm driving ‘smart’ order set at Hopkins in Medical inpatients Zeidan AM, et al. Am J Hematol. 2013; 88:545-549 Major Risk Factors Age > 60 Cancer Previous VTE Acute CVA w/ paresis (< 3 mos.) Thrombophilia Decompensated NYHA Class III/IV heart failure Respiratory failure (ventilator-dependent) …
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
    March 30, 2008 - Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems Donald K. Baker, PharmD; James M. Hoffman, PharmD; Gregory A. Hal…
  15. 0129References (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129references.pdf
    October 23, 2013 - References 1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428. 2. Wick EC, Shore AD, Hirose K, Ibrahim AM, Gearhart SL, Efron J, Weiner JP, Makary MA. Readmission rates and cost following colorectal surgery. Dis …
  16. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/002-cusp-learning-defects.pptx
    October 01, 2024 - The impact of operational failures on hospital nurses and their patients.
  17. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
    April 01, 2025 - The impact of operational failures on hospital nurses and their patients.
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
    March 15, 2016 - Documentation and Coding for Patient Safety Indicators Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety Tool B.4 i Documentation and Coding for the AHRQ Quality Indicators Note: This tool was updated based on test software provided by AHRQ as of March 2016 (alpha version…
  19. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-fullreport.pdf
    May 01, 2018 - Timely Fluid Bolus for Children With Severe Sepsis or Septic Shock 1 Timely Fluid Bolus for Children with Severe Sepsis or Septic Shock Section 1. Basic Measure Information 1.A. Measure Name Timely Fluid Bolus for Children with Severe Sepsis or Septic Shock 1.B. Measure Number 0231 1.C. Measure Descript…
  20. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/sampleransferandintakenotes.pdf
    June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Transfer Note and Intake Note Transfer Notes and Intake Notes are not required, but the elements included in them must be in the nursing home’s electronic medical record (EMR) to generate all components of the re…

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