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Showing results for "failures".
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/15886-Noskin-draft-1.pdfMarch 01, 2008 - (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
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www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/premortem-assessment.htmlOctober 01, 2024 - after a failure, a premortem is conducted proactively before a project launches, to identify potential failures
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www.ahrq.gov/research/findings/studies/index.html?page=213January 01, 2024 - Yet little is known about the nature of communication failures. … The aims of this study were to identify and describe types of communication failures in which nurses … and physicians were involved and determine how different types of communication failures might affect … The investigators found that incident reports could identify specific types of communication failures … Using incident reports to assess communication failures and patient outcomes.
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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.pdfJanuary 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 -
www.ahrq.gov/practiceimprovement/delivery-initiative/arragrantee-williams.htmlDecember 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/ .
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www.ahrq.gov/news/psaw-2021-webinars.htmlMarch 01, 2021 - High-reliability organizations sustain safe practices and avoid failures despite operating in hazardous
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170-Cusp-Science-Safety-Notes (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docxOctober 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 -
124-Cusp-Science-Safety-Fg (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docxApril 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 -
www.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.htmlOctober 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
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Final Progress Report: Process Reliability and Organizational Learning in Home Health Care (pdf file)
www.ahrq.gov/sites/default/files/2025-02/silver-report.pdfJanuary 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. -
www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.htmlAugust 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
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www.ahrq.gov/research/findings/final-reports/stpra/stpra1.htmlApril 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
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www.ahrq.gov/patient-safety/resources/vtguide/guide2.htmlFebruary 01, 2016 - The focus here is on identifying barriers to improvement and failures in the current process in order … Overcoming these failures will land the team at Level 3 on the Hierarchy of Reliability, with a projected … Diagramming helps members to understand these interrelated steps and to identify where failures—or missed
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www.ahrq.gov/teamstepps-program/evidence-base/collaboration.htmlMay 01, 2023 - a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures
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5 Tk2 P3T2-Sample Procedures Phase 3 (doc file)
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T2-Sample_Procedures_Phase_3.docJanuary 01, 1999 - The use of antibiograms can help reduce inappropriate prescribing and lead to fewer clinical failures -
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdfJanuary 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
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www.ahrq.gov/hai/patient-safety-resources/cre-toolkit/cretoolkit5.htmlApril 01, 2014 - team, and a plan to correct deficiencies should be implemented when necessary, keeping in mind that failures … For example, systemic failures can occur when— There is a lack of communication about a patient's colonization
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www.ahrq.gov/patient-safety/capacity/candor/demo-program/plan-grants/findings.htmlMay 01, 2016 - 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
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Did You Know, Safety Infographic (pdf file)
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdfAugust 01, 2021 - Did You Know, Safety Infographic Did you know... 57% of all diagnostic failures happen in ambulatory -
www.ahrq.gov/hai/cusp/modules/identify/identify.htmlDecember 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.
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