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Total Results: 385 records

Showing results for "failures".

1. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
   www.talkingquality.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.talkingquality.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.talkingquality.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.talkingquality.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.talkingquality.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. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
   www.talkingquality.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

7. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
   www.talkingquality.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.talkingquality.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.talkingquality.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.talkingquality.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.talkingquality.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. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
    www.talkingquality.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

13. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
    www.talkingquality.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.talkingquality.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. Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/research/publications/search.html
    January 01, 2024 - experiences, explores how patient-reported experiences can augment other methods of identifying diagnostic failures

16. Toolkit for Improving Perinatal Safety | Agency for Healthcare Research and Quality
    www.talkingquality.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

17. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.talkingquality.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…

18. TeamSTEPPS for Office-Based Care: Team Structure | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/teamstepps/officebasedcare/module2/office_structure.html
    September 01, 2015 - A wooden bucket labeled "Failures" contains many fish.

19. Table 4. Percent Agreement and Kappa Statistics for Sepsis for Inter-Rater Reliability at Three Study Sites (pdf file)
    www.talkingquality.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…

20. TeamSTEPPS Fundamentals Course: Module 3. Communication | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
    March 01, 2019 - Communication Failures 8—9 3 mins * 4. … Objectives TeamSTEPPS Teamwork Skills Importance of Communication (Optional) Communication Failures … Return to Contents (Optional) Communication Failures Instructor Note: Create a slide showing your