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www.ahrq.gov/research/findings/final-reports/stpra/stpra1.html
April 01, 2018 - Also important is the tool's utility in examining single-point failures, as well as combinations of events … thereby allowing the investigators to design interventions aimed at reducing the risks associated with failures
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership-cx.pdf
June 03, 2021 - Location and Impact of Diagnostic Failures
A. Balogh EP, Miller BT, Ball JR, eds. … .
edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … Reliable adherence to a COPD care bundle mitigates system-level failures
and reduces COPD readmissions
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership.pdf
June 03, 2021 - Location and Impact of Diagnostic Failures
A. Balogh EP, Miller BT, Ball JR, eds. … .
edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures. … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures … Reliable adherence to a COPD care bundle mitigates system-level failures
and reduces COPD readmissions
-
www.ahrq.gov/teamstepps-program/evidence-base/collaboration.html
May 01, 2023 - a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-creative-strategies-nembhard.pdf
January 01, 2014 - Interactions within care team for 1 patient in 80 days
Source: Press 2014
15
Care Coordination Failures … high cost: $25-45 billion in wasteful spending due to failures (Burton
2012)
16
Care Coordination … Needed
The Imperative For Care Coordination
The Imperative For Care Coordination
Care Coordination Failures
-
www.ahrq.gov/hai/cusp/modules/identify/identify.html
December 01, 2012 - Examples of Defects or Failures That Affect Patient Safety
Slide 9. … Return to Contents
Slide 8: Examples of Defects or Failures That Affect Patient Safety … Defects or failures are clinical or operational events that you do not want to happen again.
-
www.ahrq.gov/sites/default/files/2025-03/prabhakaran-holl-report.pdf
January 01, 2025 - High-criticality failures
(e.g., failure to detect LVO, failure to use screening tools) led to the design … • Failure Mode Effects and Criticality Analysis (FMECA): The LC was asked to identify failures
(weaknesses … ) in the systems and process of the DIDO process, understand the underlying causes of the
failures, … then score the frequency, harm to the DIDO process, and any existing safeguards of the
identified failures … These numbers were then rank ordered to identify the most critical failures
for solution and intervention
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
June 15, 2003 - Reporting systems
To identify system failures &
unsafe conditions that could
lead to system failures … and unsafe conditions that could lead
to system failures, and (2) redesign care processes so that all … that could lead to system failures … This requires
• Hospital staff tracking information for all systems failures and unsafe
conditions … that could lead to systems failures
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.doc
January 01, 1999 - The use of antibiograms can help reduce inappropriate prescribing and lead to fewer clinical failures
-
www.ahrq.gov/sites/default/files/2024-01/hall2-report.pdf
January 01, 2024 - Preliminary data indicated that failures were
correlated with gaps in processes. … These meetings
served to uncover process failures and to develop measures to prevent these failures. … These failures are particularly apparent across shift changes. … Not surprisingly, the process failures identified in these meetings corresponded to the gaps in care
-
www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
January 01, 2024 - The tool is used to model all
possible combinations of failures.58,59 Insights are obtained by breaking … Combinations of failures of the different tasks/
components of the system are modeled in a fault tree … (errors, at-risk behaviors,
equipment failures) possible during the dispensing process and for each … At best, data collection systems only capture the
end result, with the rate of intermediate failures … Failures, at-risk behaviors, and adverse
events are underreported, making any data source relying on
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
August 01, 2021 - Did You Know, Safety Infographic
Did you know...
57%
of all diagnostic
failures happen in
ambulatory
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.pdf
May 01, 2014 - The use of antibiograms can help reduce inappropriate
prescribing and lead to fewer clinical failures
-
www.ahrq.gov/nursing-home/materials/prevention/observational-audits.html
July 01, 2021 - occur while staff are in the work environment and help obtain accurate compliance rates and process failures
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T1-Sample_Policy_Phase_3.doc
May 01, 2014 - helps reduce reliance on broad-spectrum antibiotics as initial therapy and leads to fewer clinical failures
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T1-Sample_Policy_Phase_3.pdf
May 01, 2014 - helps reduce reliance on broad-spectrum antibiotics as
initial therapy and leads to fewer clinical failures
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
April 01, 2025 - found keen insights from Reason’s Swiss Cheese Model , which asserts that adverse events result from failures … Safety-I often defines factors that contribute to adverse events as failures or errors, even if it uses … capacity to diagnose adequately and correctly may be increased by studying diagnostic successes as well as failures
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T3-Antibiogram_Factsheet_Phase_3.doc
January 01, 2014 - reduced reliance on broad-spectrum antibiotics as initial therapy and can result in fewer clinical failures
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P1T4-Antibiogram_Factsheet_Phase_1.doc
January 01, 2014 - reduced reliance on broad-spectrum antibiotics as initial therapy and can result in fewer clinical failures
-
www.ahrq.gov/diagnostic-safety/workgroup/index.html
July 01, 2025 - address the lack of dedicated research into improving medical diagnosis and in particular, diagnostic failures