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Showing results for "failures".

41. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
    January 01, 2024 - HS012032 1 Abstract Purpose: The goals of this study were to compare work hours, sleep, attentional failures … schedule worked 19 hours more per week, slept 5.8 hours less per week, and had twice as many attentional failures … The report found that errors in healthcare should be seen as the results of complex system failures … Attentional failures were identified by means of continuous electrooculography (EOG) and defined as … , alertness, and slow eye movement data provide a strong basis for the conclusion that attentional failures

42. Final Progress Report: Validation of an Innovative Approach to Error Reduction (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/blumenthal-report.pdf
    January 01, 2024 - STRUCTURED ABSTRACT Purpose: To determine if reports by emergency department (ED) personnel about failures … This study responds to the need for error reduction methods, with a focus on the correction of failures … We also added questions to assess specific ED process failures that might contribute to errors. … Serious failures (also called “critical errors”) will be grouped with preventable adverse events in … To increase the generalizability of the study, we also examined charts for the occurrence of failures

43. Identify Defects Module Alternate Text | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/modules/identify/alt-text.html
    March 01, 2013 - CUSP uses the term "defect" while Sensemaking uses the term "failure" and further classifies failures … Cause Analysis, Failure Mode and Effects Analysis, and Probabilistic Risk Assessment tools to identity failures … Learn From Defects Form to examine defects while Sensemaking uses the Causal Tree Worksheet to examine failures … uses the Learn From Defects Form to code defects, while Sensemaking uses the Eindhoven Model to code failures … Identifying Defects Identify defects and Sensemaking share several common themes Defects or failures

44. AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/index.html
    July 01, 2023 - units and decrease maternal and neonatal adverse events resulting from poor communication and system failures

45. Final Progress Report: Cardio-HIT Phase II (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/kmetik-otoole-report.pdf
    January 01, 2024 - of identified failures that were true failures was within 5% of the same proportion among the entire … A second limitation of our study was the restriction of validation to apparent quality failures, as … • Among patients with “apparent quality failures,” 22.4% (95% CI: 17.6%, 27.9%) actually were found … For these measures, quality failures would have been overestimated were reporting of exceptions not … Our finding that approximately 75% of cases considered apparent quality failures by automatic query

46. Final Progress Report: Medications at Transitions and Clinical Handoffs (MATCH) (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/noskin-report.pdf
    January 01, 2024 - (3) To determine the rate and etiology of medication reconciliation failures within the general medicine … MATCH that other acute care hospitals can use to implement programs to reduce medication reconciliation failures … The effects of health literacy and cognition as risk factors for medication reconciliation failures … Also, early identification and correction of medication reconciliation failures may mitigate or prevent … Medications At Transitions and Clinical Handoffs (MATCH): Risk factors for medication reconciliation failures

47. Impact of Pharmacy-led Dyslipidemia Interventions on Medication Safety and Therapeutic Failure in Patients (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weaver.pdf
    January 01, 2003 - Results demonstrated significant improvements in LDL values among patients with previous therapeutic failures … Failures requiring atorvastatin as an alternate agent were defined as (a) patients not at their LDL … Category 4 incorporates treatment selection according to PEC guidelines on therapeutic failures. … Comparison of barrier analysis for therapeutic failures Acknowledgments The authors would like … Comparison of barrier analysis for therapeutic failures << /ASCII85EncodePages false

48. Part Four: A Research Agenda To Advance the Science of Physician Feedback Reporting Systems | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/tools/confid-report/research-agenda.html
    March 01, 2016 - Identify implementation failures ( Grimshaw, 2015 ). … As much can be learned from implementation failures as from successes yet null findings on any topic … To better enable the identification of failures, efforts to more systematically identify and centrally

49. Getting Started Laying the Groundwork Coordination for Implementing Automatic Referral & Effective Care
    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-slides.pptx
    December 31, 2022 - Then use a fishbone diagram to categorize process failures that need to be addressed. … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures

50. About the Toolkit Development | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
    July 01, 2023 - In addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication

51. Final Progress Report: Risk Assessment of the Testing Processes of Access Community Health Network (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/eder-report.pdf
    January 01, 2024 - physician awareness of safety issues in the testing processes and to identify specific instances of failures … yielded quantitative pilot data on areas in the community health center lab testing process where failures … Documentation Failures in Patient Medical Records n=2008 tests Test result not in chart 14% No provider … Number of cases in which there was one or more documentation Test Type failures Testing … This risk assessment highlighted failures to notify patients of important test results related to

52. Performing a Premortem Assessment | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/premortem-assessment.html
    October 01, 2024 - after a failure, a premortem is conducted proactively before a project launches, to identify potential failures

53. 170-Cusp-Science-Safety-Notes (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
    October 01, 2024 - Active Failures are identified when an “operator” performs an unsafe event. … Latent Failures are decisions or actions dormant in an organization until revealed by active failures … In other words, active failures are the adverse events we are used to thinking about and attempt to avoid … Latent failures are the “holes in the system”—the weaknesses that could allow an active failure to happen … Story – Part 1 SAY: Let’s review a specific patient’s experience and identify the system factors and failures

54. 124-Cusp-Science-Safety-Fg (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
    April 01, 2025 - Active Failures are identified when an “operator” performs an unsafe event. … Latent Failures are decisions or actions dormant in an organization until revealed by active failures … In other words, active failures are the adverse events we are used to thinking about and attempt to avoid … Latent failures are the “holes in the system”—the weaknesses that could allow an active failure to happen … safety, detailing an example of a specific patient’s experience and identifying the system factors and failures

55. Module-5-Slides (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-slides.pdf
    December 31, 2022 - Leaping  Changing and redesigning CR workflow processes to overcome your current problems and process failures … important  How you implemented AR  Key advice for peers just starting the process Causes of Failures … set, notify the CR program, a combination of approaches) the referral should be made These are the failures … bother Implicit biases excluded from automated referral How Automatic Referral Addresses Process Failures

56. ARRA Delivery System Initiative | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/delivery-initiative/arragrantee-williams.html
    December 01, 2017 - Bundled payment: learning from our failures. Health Affairs Blog 2014 Aug 5. … http://healthaffairs.org/blog/2014/08/05/bundled-payment-learning-from-our-failures/ .

57. Final Progress Report: Process Reliability and Organizational Learning in Home Health Care (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
    January 01, 2025 - , in 46 cases (23.6%) the unplanned hospitalization was determined to be the result of care process failures … The dominant failure mode identified was care planning, implicated in 69.6% of cases, followed by failures … • Detail on care planning failures that contributed to preventable hospitalizations is provided in … These failures represent a mismatch between the patient’s needs and the skills included in the care plan … None have processes for systematically identifying and learning from such failures. 3.

58. Findings | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
    August 01, 2022 - examined patient, family, and clinician attitudes about the disclosure of individual, team, and system failures … group and survey data revealed that patients and their family members tended to agree on which system failures … The highest correlation in patient/family member and clinician responses was found in regard to failures … researchers collected and reviewed the hospital’s clinical and administrative documents to identify potential failures … Themes and subthemes emerging from the analysis suggest failures may occur in multiple domains of the

59. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
    www.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
    October 01, 2023 - In general, failures in communication about changes in medication doses were common, and one in four … on preventing harm in children caused by the outpatient healthcare system, specifically identifying failures

60. Barriers Associated with Medication Information Handoffs (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
    January 01, 2004 - The group brainstormed both failures and their effects. … Failures associated with medication information transfer The major failures associated with medication … Admission failures include omitted medications, altered doses, or missed allergies. … Several of the failures emerging from the FMEA were corroborated via chart review. … Many failures, such as those associated with illegibility, miscommunication, and limited information