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Showing results for "failures".

401. Major Study Finds Significant National Patient Safety Improvement | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/press-releases/significant-patient-safety-improvement.html
     July 01, 2022 - Major Study Finds Significant National Patient Safety Improvement Press Release Date: July 12, 2022 A study published in JAMA: The Journal of the American Medical Association ( JAMA ) and funded and carried out by Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ) shows that rates…

402. Assess-Resident-Rti-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/assess-resident-RTI-facilitator-guide.docx
     June 01, 2021 - AHRQ Safety Program for Improving Antibiotic Use 1 Assessment of the Resident With a Suspected Respiratory Tract Infection Long-Term Care Slide Title and Commentary Slide Number and Slide Assessment of the Resident With a Suspected Respiratory Tract Infection Long-Term Care SAY: Thank you for joining us. This…

403. Improving Healthcare Safety by Enhancing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-medication-safety.pdf
     April 30, 2025 - Also, early identification and correction of medication reconciliation failures may mitigate or prevent … The researchers also found that the same types of system failures that plague inpatient medical settings … Remedying these system failures in outpatient settings is likely more complex than inpatient failures … They provide contextual maps of errors and behaviors leading to system failures so that policymakers … of execution, failures of intention, and complexities of the working environment.

404. TAKEheart Learning Community Webinars | Agency for Healthcare Research and Quality
     www.ahrq.gov/takeheart/training/learning-community-webinars/index.html
     December 01, 2022 - TAKEheart Learning Community Webinars TAKEheart Learning Community webinars, held between 2020–2022, featured discussions among cardiac rehabilitation (CR) experts and CR champions from diverse hospitals. Panelists shared knowledge and resources for addressing common challenges to increasing CR enrollment, part…

405. Final Progress Report: Reducing Diagnostic Errors in Primary Care Pediatrics (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/rinke-report.pdf
     January 01, 2025 - The QIC intervention included day-long video conferences, transparent data sharing, analysis of failures … to reduce these misdiagnoses through collaboration, data benchmarking, QI coaching, and focusing on failures … and training of providers to respond to alerts and to document consistently to avoid communication failures

406. Premortem Assessment | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mrsa-prevention/surgery/premortem-assessment.html
     April 01, 2025 - MRSA Prevention Toolkit: Targeting SSI Premortem Assessment Previous Page Next Page Table of Contents MRSA Prevention Toolkit: Targeting SSI The Four Key Strategies of MRSA Prevention: Targeting SSI MRSA and SSI Prevention Phases The Evidence for MRSA Decolonization Nasal Decolonization Us…

407. Tool 6: How To Monitor RED Implementation and Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool6.html
     March 01, 2025 - and structured interviews with patients, DEs, and other providers, you will uncover the underlying failures … Action to prevent future failures involves reaching consensus for what changes are needed, setting goals

408. Implementation Guide: MRSA and SSI Prevention (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/147-implementation-guide.pdf
     April 01, 2025 - Every system, no matter how well designed, will include failures. … Performing a CUSP Premortem Project Assessment is a proactive method to identify potential future risks and failures

409. Tool 6: How To Monitor RED Implementation and Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool6.html
     March 01, 2025 - and structured interviews with patients, DEs, and other providers, you will uncover the underlying failures … Action to prevent future failures involves reaching consensus for what changes are needed, setting goals

410. ASTD Coaching Self-Assessment Form (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/astd-coaching-self-assessment-form.pdf
     June 02, 2025 - ASTD Coaching Self-Assessment Form ASTD Coaching Self-Assessment Form Instructions The purpose of this activity is to assist you in learning about what you need to be successful as a coach an…

411. Contemporary Emergency Medical Treatment and Labor Act (EMTALA) Clinical Issues Involving Pregnant Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/contemporary-EMTALA-clinical-issues-pregnantpts.pdf
     December 01, 2024 - Contemporary Emergency Medical Treatment and Labor Act (EMTALA) Clinical Issues Involving Pregnant Patients 1 Contemporary Emergency Medical Treatment and Labor Act (EMTALA) Clinical Issues Involving Pregnant Patients Prepared by: Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, …

412. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/169-cusp-science-safety-slides.pptx
     October 01, 2024 - Non-ICU The Science of Safety 18 Swiss Cheese Model: How Errors Happen10 But sometimes holes (i.e., failures

413. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcarae Meeting (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2023.pdf
     January 01, 2025 - Annual review of malpractice claims paid shows a similar pattern as previous years with regard to failures

414. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
     January 01, 2024 - points: 1) the extent of harm that results from medical errors is great; 2) errors result from systems failures … , not people failures; 3) achieving acceptable levels of patient safety will require major systems changes

415. Final Progress Report: A Memory-Based Approach to Reducing Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/kazi-report.pdf
     January 01, 2024 - We also identified electronic health record (EHR) signals of PM failures for anticoagulant therapy ( … approaches that apply general error taxonomies to classify types of MAEs find that lapses – memory-related failures

416. 3. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
     January 01, 2024 - Communication failures. System factors. … Failure to close the loop can occur due to failures in timely followup of abnormal laboratory results

417. ASC, Report Output, Report: 'Fault Tree Diagram', Data Source File: 'ASC Fault Tree_with_change' (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/stpra/stpraapf.pdf
     June 02, 2025 - ASC, Report Output, Report: 'Fault Tree Diagram', Data Source File: 'ASC Fault Tree_with_change' Fault Tree Diagram File Name: ASC Fault Tree_with_change.RFP Gate347 SSI Risk Q:0.00436584 Gate2 Pt SSI risk Q:0.0281772 From Page 2 Gate18 Bug moves to SS Q:0.154943 F…

418. Risk-Based Patient Safety Metrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
     March 25, 2008 - In contrast, both error- and injury-based metrics essentially provide a count of organizational failures … value a metric emphasizing and reinforcing improvement over one that provides a reminder of system failures

419. VA Provides Specialty Care in Local Offices Across the Country | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cp31307.html
     May 01, 2013 - VA Provides Specialty Care in Local Offices Across the Country Search All Impact Case Studies May 2013 The U.S. Department of Veterans Affairs (VA) has launched a virtual model of medical education to deliver health care that is based on AHRQ's "Project Extension for Community Healthcare Outcomes" (Project …

420. Chapter 5. Project Findings for Goal 1 | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter5.html
     December 01, 2017 - ARRA ACTION: Comparative Effectiveness of Health Care Delivery Systems for American Indians and Alaska Natives Using Enhanced Data Infrastructure Chapter 5. Project Findings for Goal 1 Previous Page Next Page Table of Contents ARRA ACTION: Comparative Effectiveness of Health Care Delivery Systems fo…