Results

Total Results: 2,785 records

Showing results for "failures".

81. Creative Strategies to Improve Patient Care Experience - Part 3 Nemhard (pdf file)
    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

82. 5 Tk2 P3T2-Sample Procedures Phase 3 (pdf file)
    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

83. TeamSTEPPS®: Research/Evidence Base | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps/evidence-base/phys-nurse-collab.html
    July 01, 2015 - a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures

84. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
    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

85. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
    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

86. Final Progress Report: Enhancing Stroke Prehospital and Emergency Evaluation and Delivery (pdf file)
    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

87. 5 Tk2 P3T1-Sample Policy Phase 3 (doc file)
    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

88. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
    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

89. Final Progress Report: Safety Advancement in the Emergency Department (pdf file)
    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

90. Final Progress Report: Safety Advancement in the Emergency Department (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/17904-Hall-report.pdf
    September 18, 2023 - 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

91. How To Learn More About CUSP With the CUSP Toolkit | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/cusp-success/learnmore.html
    September 01, 2012 - such as TeamSTEPPS®, Just Culture, and Sensemaking, a deliberate process of reflection on defects, failures

92. 5 Tk2 P3T1-Sample Policy Phase 3 (pdf file)
    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

93. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.html
    June 01, 2023 - That promise holds similar appeal for addressing diagnostic failures. 9 As one paper concluded, “Insights … in three broad (somewhat overlapping) categories: delays in diagnosis, missed or misdiagnosis, and failures … event occurred at all. 39 , 47 That may lead to systematic underreporting of more complex diagnostic failures

94. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
    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

95. Auditing Strategies to Improve Infection Prevention Processes in Nursing Homes | Agency for Healthcare Research and Quality
    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

96. 5 Tk2 P3T3-Antibiogram Factsheet Phase 3 (doc file)
    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

97. 5 Tk2 P1T4-Antibiogram Factsheet Phase 1 (doc file)
    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

98. TeamSTEPPS®: National Implementation Research/Evidence Base | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps/evidence-base/surgical-care.html
    July 01, 2015 - Communication failures in the operating room: An observational classification of recurrent types and … a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures

99. 5 Tk2 P3T3-Antibiogram Factsheet Phase 3 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T3-Antibiogram_Factsheet_Phase_3.pdf
    May 01, 2014 - reduced reliance on broad-spectrum antibiotics as initial therapy and can result in fewer clinical failures

100. 5 Tk2 P1T4-Antibiogram Factsheet Phase 1 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P1T4-Antibiogram_Factsheet_Phase_1.pdf
     May 01, 2014 - reduced reliance on broad-spectrum antibiotics as initial therapy and can result in fewer clinical failures