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Total Results: 414 records

Showing results for "failures".

1. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
   www.cpsi.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.cpsi.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. Hand Hygiene Observational Audit Tracking Tool (xls file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
   December 01, 2021 - per Assessment for Job: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 Month … per Assessment for Job: Average # Failures per Audit - - - - - - - - - - #N/A … per Assessment for Location: Average # Failures per Audit Month_1 Month_2 Month_3 Month_4 Month_5 … per Assessment for Location: Average # Failures per Audit - - - - - - - - - - … Skin is intact without open wounds or rashes # Failures

4. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
   www.cpsi.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.

5. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
   www.cpsi.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

6. Chapter 2. What is Care Coordination? | Agency for Healthcare Research and Quality
   www.cpsi.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

7. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
   www.cpsi.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.

8. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
   www.cpsi.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.

9. Lafleur, Joanne | Agency for Healthcare Research and Quality
   www.cpsi.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

10. 5 Tk2 P3T3-Antibiogram Factsheet Phase 3 (pdf file)
    www.cpsi.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. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
    www.cpsi.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

12. TeamSTEPPS Research/Evidence Base: Surgical Care and OR | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps-program/evidence-base/surgical.html
    July 01, 2023 - 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

13. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
    January 01, 2024 - classic framework to identify and classify both latent and active errors,14 examining errors such as failures … in preventive practices that reduce adverse medication events and failures in safety monitoring for … Failures in preventive practices that are known to reduce adverse events included failures to determine … patients who plan to begin CD20-depleting therapies such as rituximab.16 Thus, we examined process failures

14. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
    www.cpsi.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

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

16. TeamSTEPPS Research/Evidence Base: Physician/Nurse Collaboration | Agency for Healthcare Research and Quality
    www.cpsi.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

17. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
    www.cpsi.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.

18. About the Toolkit Development | Agency for Healthcare Research and Quality
    www.cpsi.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

19. TeamSTEPPS Research/Evidence Base: Anesthesiology | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps-program/evidence-base/anesthesiology.html
    May 01, 2023 - a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures

20. Figure 11: Comparison of Audit Techniques | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/hospital/match/figure-11.html
    July 01, 2022 - intervention (MD, RN, RPh, reviewer) and also shows missed opportunities (medication reconciliation failures