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Total Results: 335 records

Showing results for "failures".

1. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
   July 01, 2023 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

2. Learn-From-Defects-Facilitator-Guide (doc file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
   May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

3. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
   May 01, 2017 - Active failures are also called human error. … Latent conditions are sorted into two categories: technical failures and organizational failures. … • Technical failures are problems with physical items, such as equipment and software. … Tools to identify defects or failures When identifying defects or failures, CUSP uses the Staff Safety … Remember to consider both active failures and latent conditions.

4. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
   May 01, 2017 - Failure Mode and Effects Analysis - Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects Form Eindhoven … 6 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Examples of Defects or Failures … Sensemaking and Learn From Defects Sensemaking and Learn From Defects share several common themes Defects or failures

5. Chapter 2. What is Care Coordination? | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/ncepcr/care/coordination/atlas/chapter2.html
   June 01, 2014 - Perspectives on Care Coordination Successes and failures in care coordination will be perceived (and … and sites are met over time. 4 Patients, their families, and other informal caregivers experience failures … Patients perceive failures in terms of unreasonable levels of effort required on the part of themselves … They also perceive failures in terms of unreasonable levels of effort required on their part in order … Successes and failures in care coordination will be perceived (and may be measured) in different ways

6. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
   January 01, 2004 - Unlike active failures, which are difficult to predict, latent conditions can be identified and remedied … The learning lab also identified 10 precarious events (active failures) that were the result of JACHO … Errors in health care, like human failures in any other sphere, are not just isolated causes; they are … Advances in Patient Safety: Vol. 2 430 Active failures Operative/postop complications/infections … This will result in reducing the latent conditions and active failures that lead to error.

7. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
   July 01, 2023 - Failure Mode and Effects Analysis Probabilistic Risk Assessment Tools to examine defects or failures … Learn From Defects Form Causal Tree Worksheet Coding defects or failures Learn From Defects … Slide 7: Examples of Defects or Failures That Affect Patient Safety Defect Intervention Medication … Defects or failures are clinical or operational events that you do not want to happen again.

8. Lafleur, Joanne | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumlafl.html
   October 01, 2014 - The grantee is interested in identifying and preventing drug-therapy failures in chronic disease populations … She is focusing on the clinical area of osteoporosis for systems interventions to prevent such failures

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

10. 5 Tk2 P3T3-Antibiogram Factsheet Phase 3 (pdf file)
    www.cahps.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

11. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
    www.cahps.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

12. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/diagnostic-safety/workgroup/index.html
    March 01, 2024 - address the lack of dedicated research into improving medical diagnosis and in particular, diagnostic failures

13. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/resources/learning-lab/index.html
    February 01, 2024 - Using incident reports to assess communication failures and patient outcomes . … The PIQS Lab examined radiology imaging failures through similar conceptual lenses of shared sense making … The specific aims are to: Explore solutions to failures in diagnosis, selection, and prescribing of … Develop methods to reduce failures in the preparation, administration, and recording of intraoperative … /19-09/09/23 Description: This project addresses diagnostic errors in primary care often caused by failures

14. AHRQ's Quality & Patient Safety Programs by Setting: Hospital Labor and Delivery Units | Agency for Healthcare Research and Quality
    www.cahps.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

15. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
    April 27, 2022 - Newman- The author distinguishes between diagnostic process failures and diagnostic labeling failures … Diagnostic process failures are Toker10 problems in the diagnostic workup. … Diagnosis label failures are an incorrect diagnosis or no attempt at a diagnosis. … Preventable diagnostic error is the overlap between diagnostic process failures and diagnostic label … failures.

16. About the Toolkit Development | Agency for Healthcare Research and Quality
    www.cahps.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

17. Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/research/publications/search.html
    January 01, 2024 - experiences, explores how patient-reported experiences can augment other methods of identifying diagnostic failures

18. Toolkit for Improving Perinatal Safety | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/index.html
    July 01, 2023 - units and decrease maternal and neonatal adverse events resulting from poor communication and system failures

19. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
    May 17, 2016 - Selected Best Practices and Suggestions for Improvement Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool D.4u Selected Best Practices and Suggestions for Improvement PDI 09: Postoperative Respiratory Failure Why focus on postoperative respiratory failure in chi…

20. Table 4. Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-section-6-table-4.pdf
    April 30, 2018 - Table 4. Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites Table 4: Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites Site Eligibility Criteria/ Measure Numerator Number of Records R i d N Agreed (%) Kappa St…