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Showing results for "failures".

381. Tool 6 (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool-other.html
     March 01, 2013 - Re-Engineered Discharge (RED) Toolkit Tool 6 (continued) Previous Page   Table of Contents Re-Engineered Discharge (RED) Toolkit Tool 1: Overview Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital How CMS Measures the "30-Day All Cause Rehospitalization Rate" on t…

382. Tool 6 (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool-other.html
     March 01, 2013 - Re-Engineered Discharge (RED) Toolkit Tool 6 (continued) Previous Page   Table of Contents Re-Engineered Discharge (RED) Toolkit Tool 1: Overview Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital How CMS Measures the "30-Day All Cause Rehospitalization Rate" on t…

383. NICU Family Information Packet, Appendix B, Bronchopulmonary Dysplasia (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-bpd.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Bronchopulmonary Dysplasia Bronchopulmonary Dysplasia Characteristics ■ Need for supplemental oxygen at 36 weeks postmenstrual age, with radiographic changes on chest x-ray (bilateral, diffuse hazy lungs; interstitial thickening; increased lung inflation). ■ Symptoms: …

384. Interplay Between Cognitive Load and Diagnostic Accuracy | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
     May 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy Interplay Between Cognitive Load and Diagnostic Accuracy Previous Page Next Page Table of Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors Fundamental Concepts for Understanding Cogn…

385. Situation Monitoring: Severe Hypertension (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring-speaker-notes.pdf
     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

386. Module-5-Implementation-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-implementation-guide.pdf
     June 02, 2025 - • Review the referral process failures identified during the mapping exercise in Module 3.

387. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb.html
     December 01, 2013 - Transitioning Newborns from NICU to Home Appendix B. Clinical Materials to Share With Primary Care Providers Previous Page Next Page Table of Contents Transitioning Newborns from NICU to Home A Resource Toolkit Basic Components of the Health Coach Program Family Information Packet Cover Sheet …

388. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb.html
     December 01, 2013 - Transitioning Newborns from NICU to Home Appendix B. Clinical Materials to Share With Primary Care Providers Previous Page Next Page Table of Contents Transitioning Newborns from NICU to Home A Resource Toolkit Basic Components of the Health Coach Program Family Information Packet Cover Sheet …

389. Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Shimada_65.pdf
     April 04, 2008 - Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration Stephanie L. Shimada, PhD; Maria E. Montez-Rath, PhD; Susan A. Loveland, MAT; Shibei Zhao, MPH; Nancy R. Kressin, PhD; A…

390. Catheter Ablation for Atrial Fibrillation: Topic Refinement - Project ID: CRDT0913 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdf
     January 01, 2020 - Catheter Ablation for Atrial Fibrillation: Topic Refinement - Project ID: CRDT0913 Final Topic Refinement Document Catheter Ablation for Atrial Fibrillation - Project ID: CRDT0913 Date: 05/29/2014 Topic: Catheter Ablation for Atrial Fibrillation – Project ID: CRDT0913 EPC: Pacific Northwest EPC AHRQ Task …

391. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     December 01, 2017 - Finally, individual patient characteristics can and do contribute to system failures. … that worked in normal situations failed in an emergent one. 28 Case Study: Renal Transplant System Failures … When evaluating the defect as a system issue, we find many systems failures in the knowledge, skills, … Case Study: Renal Transplant System Failures Knowledge, Skills & Competence Anesthesiology attending

392. References (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-131-references.pdf
     October 23, 2013 - References References 1. Berry JG, Toomey SL, Zaslavsky AM, Jha AK, Nakamura MM, Klein DJ, Feng JY, Shulman S, Chiang VK, Kaplan W, Hall M, Schuster MA. Pediatric readmission prevalence and variability across hospitals. JAMA. 2013;309(4):372–380. 2. Pelletier AJ, Mansbach JM, …

393. TeamSTEPPS Video-Based Simulation: Facilitator Guide Module 4 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/module-4-mutual-support-facilitator-worksheet.pdf
     June 02, 2025 - TeamSTEPPS Video-Based Simulation: Facilitator Guide Module 4 …

394. Sustaining Stewardship Activities Acute Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/sustain-facilitator-guide.pdf
     November 01, 2019 - antibiotic duration from 14 days to 7 days for hospital-acquired pneumonia will not lead to more treatment failures

395. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/prescribers-slides.pptx
     June 01, 2021 - Communicating With Prescribers 2 Communication Errors Can Have Disastrous Effects1-3 Communication failures

396. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
     July 14, 2023 - Annual review of malpractice claims paid shows a similar pattern as previous years with regard to failures

397. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits - Transfer Note and Intake Note (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-trans-intakenotes.pdf
     June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits - Transfer Note and Intake Note 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 elemen…

398. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
     January 01, 2024 - Final Progress Report: Medication Error Reduction, Technologies and Human Factors Medication Error Reduction, Technologies, and Human Factors Final Report Pascale Carayon, PI, Tosha B. Wetterneck, co-PI Roger Brown Professor, UW School of Nursing Pascale Carayon Principal investigator; Professor, Department of …

399. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-handouts.html
     June 01, 2017 - 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…

400. Case Study | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/ena-slides/case-study.html
     October 01, 2015 - The Emergency Nurses Association Presents CAUTI Slides and Transcript Case Study Previous Page Next Page Table of Contents The Emergency Nurses Association Presents CAUTI Slides and Transcript Opening Materials: Attribution, Objectives, Introduction, and Main Menu Part One: Traditional Practice …