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Showing results for "failures".

1. PowerPoint Presentation
   www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
   June 01, 2021 - an opportunity to prevent the same problem from occurring again System design Can result in “latent” failures … Human behavior Can result in “active” failures 3 Changing the System 3 System Failures System failures … Errors that occur because of individual actions Generally readily apparent Examples of active failures … Organizational Influences – Latent failures Unsafe acts – Active failures Unsafe supervision – Latent … 17 Changing the System 17 Review Consider system/active failures which may have led to the problem

2. Changing-System-Facilitator-Guide (doc file)
   www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
   June 01, 2021 - These result in latent failures. … These result in active failures. … Slide 3 System Failures SAY: System failures are considered latent problems. … Slide 4 Active Failures SAY: Active failures occur because of human error. … Does the problem you are addressing involve latent failures, active failures, or both?

3. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
   www.qualitymeasures.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.

4. Learn-From-Defects-Facilitator-Guide (doc file)
   www.qualitymeasures.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.

5. Hand Hygiene Observational Audit Tracking Tool (xls file)
   www.qualitymeasures.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

6. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
   www.qualitymeasures.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.

7. Module-3-Implementation-Guide (pdf file)
   www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-implementation-guide.pdf
   February 13, 2023 - attendees will be able to: • Understand the importance of mapping key processes and identifying process failures … • Identify implementation gaps and process failures that must be addressed to support automatic … as well as specific failures that fall into these general categories. … Several specific failures prevent patients from being identified as eligible for CR. … Other failures relate to activities or beliefs of cardiologists as well as patients that are eligible

8. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects
   www.qualitymeasures.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

9. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
   www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
   April 01, 2021 - The tracking tool only extracts the failures in each category, so you are only required to select "NO … The tab will then automatically calculate how many “Not Met” observations or failures, were recorded … provides a high-level summary of the audit data for your facility, including and the average number of failures … (NO/Not Met) per audit, and a breakdown of where the failures are occurring by both line item (#1 - … The Summary Rates tab provides graphs outlining the average number of failures per audit and the hand

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

11. Module-3-Slides (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-3-slides.pdf
    February 09, 2022 - Learning Goals 6 Understand the importance of mapping key processes and identifying process failures … Identify implementation gaps and process failures that must be addressed to support automatic referral … Insights From Workflow Process Maps 22 PARTICIPANTS Use process maps to identify process gaps and failures … Use Fishbone diagrams to group failures into categories that your redesigned processes will need … Failure to refer all patients eligible for CR Patient objection to referral Referral process failures

12. Getting Started Laying the Groundwork Coordination for Implementing Automatic Referral & Effective Care
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/getting-started-slides.pptx
    December 31, 2022 - Then use a fishbone diagram to categorize process failures that need to be addressed. … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures … Fishbone diagrams are a useful way to identify major causes of process failures as well as specific failures

13. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
    www.qualitymeasures.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.

14. Module 3: Systems Change: Understanding Your Workflow Processes To Prepare for System Change | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/takeheart/training/module-3/index.html
    December 01, 2022 - attendees should be able to: Understand the importance of mapping key processes and identifying process failures … Identify implementation gaps and process failures that must be addressed to support automatic referral

15. Module-5-Slides (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-5-slides.pdf
    December 31, 2022 - Leaping  Changing and redesigning CR workflow processes to overcome your current problems and process failures … important  How you implemented AR  Key advice for peers just starting the process Causes of Failures … set, notify the CR program, a combination of approaches) the referral should be made These are the failures … bother Implicit biases excluded from automated referral How Automatic Referral Addresses Process Failures

16. Lafleur, Joanne | Agency for Healthcare Research and Quality
    www.qualitymeasures.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

17. Did You Know, Safety Infographic (pdf file)
    www.qualitymeasures.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

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

19. 5 Tk2 P3T3-Antibiogram Factsheet Phase 3 (pdf file)
    www.qualitymeasures.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

20. Chapter 1. Introduction | Agency for Healthcare Research and Quality
    www.qualitymeasures.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