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Showing results for "failures".

4801. Phone Call Role Play (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/phoneroleplay.pdf
      June 02, 2025 - Phone Call Role Play 1 Phone Call Role Play CALLER: Hello Ms. Smith, I am Brian, a nurse from [Hospital]. When you left the hospital, Lynn, your discharge educator, mentioned you’d receive a call checking in on things and I’m glad to help with this call. I am hoping to talk to you about your medical issues, see …

4802. Phoneroleplay (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/phoneroleplay.docx
      June 02, 2025 - Phone Call Role Play CALLER: Hello Ms. Smith, I am Brian, a nurse from [Hospital]. When you left the hospital, Lynn, your discharge educator, mentioned you’d receive a call checking in on things and I’m glad to help with this call. I am hoping to talk to you about your medical issues, see how you are doing, and see if …

4803. Improving Quality through Decision Support for Evidence-Based Pharmacotherapy | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/improving-quality-through-decision-support-evidence-based-pharmacotherapy
      January 01, 2023 - Improving Quality through Decision Support for Evidence-Based Pharmacotherapy Project Final Report ( PDF , 1.02 MB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily repres…

4804. Focus Group Consent Form (Spanish) | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/ahrq-funded-project-resources-archives/focus-group-consent-form
      January 01, 2023 - Focus Group Consent Form (Spanish) Description Example consent form used in an AHRQ-funded project involving older adults. The study involves a focus group on medication management practices. The form is in Spanish. Document Type Informed Consent Document Document Source…

4805. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36353/psn-pdf
      October 27, 2010 - Ways to avert potential patient care disasters. October 27, 2010 Spath P. Ways to avert potential patient care disasters. Hospital peer review. 2006;31(9):128-30. https://psnet.ahrq.gov/issue/ways-avert-potential-patient-care-disasters This article discusses clinician failure to recognize patient deterioration and …

4806. Dental Recommendations for Preventing Complications in Patients with Chronic Conditions | Digital Healthcare Research
      digital.ahrq.gov/health-it-tools-and-resources/ahrq-funded-project-resources-archives/dental-recommendations
      January 01, 2023 - Dental Recommendations for Preventing Complications in Patients with Chronic Conditions Description Guidelines used in an AHRQ study in which CDS was used to generate alerts within a electronic dental record and personal health record system. Document Type Clinical/Practice Guid…

4807. Development of Dashboards To Provide Feedback To Home Care Nurses - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs023855-dowding-final-report-2017.pdf
      January 01, 2017 - Development of Dashboards To Provide Feedback To Home Care Nurses - Final Report 1 DEVELOPMENT OF DASHBOARDS TO PROVIDE FEEDBACK TO HOME CARE NURSES Principal Investigator: Dawn Dowding,1,2 PhD, RN, FAAN Team Members: David Russell,1 PhD Jacqueline Merrill,2 PhD, MPH, RN, FAAN, FACMI Yolanda Barrón…

4808. R18Hs017163-Baker-Final-Report-2011 (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017163-baker-final-report-2011.pdf
      January 01, 2011 - 1 FINAL REPORT Using Precision Performance Measurement to Conduct Focused Quality Improvement Principal Investigator: David W. Baker, MD, MPH Team Members: Steven Persell, MD, MPH; Abel Kho, MD; Nancy Dolan, MD; Muriel Jean- Jacques, MD Organization: Northweste…

4809. Trends in Hospital Readmissions for Four High-Volume Conditions, 2009-2013 #196
      hcup-us.ahrq.gov/reports/statbriefs/sb196-Readmissions-Trends-High-Volume-Conditions.jsp
      November 01, 2015 - Trends in Hospital Readmissions for Four High-Volume Conditions, 2009-2013 #196 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us …

4810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72739/psn-pdf
      February 10, 2021 - In complex systems, holes are constantly opening, closing, and shifting; holes arise due to active failures

4811. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism | PSNet
      psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
      December 31, 2024 - In complex systems, holes are constantly opening, closing, and shifting; holes arise due to active failures

4812. Implementing the SPPC‐II Teamwork Toolkit (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_7-implementation-speaker-notes.pdf
      July 01, 2023 - "Spend the next 10 minutes writing down all the reasons you believe these failures occurred.

4813. Implementing the SPPC-II Teamwork Toolkit (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_7-implementation-speaker-notes.pdf
      July 01, 2023 - "Spend the next 10 minutes writing down all the reasons you believe these failures occurred.

4814. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37110/psn-pdf
      October 06, 2011 - Seeing systems in health care organizations. October 6, 2011 Friedman LH, King JB, Bella D. Seeing systems in health care organizations. Physician Exec. 2007;33(4):20-9. https://psnet.ahrq.gov/issue/seeing-systems-health-care-organizations Using a hypothetical scenario, the authors illustrate how to use the system…

4815. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38794/psn-pdf
      July 15, 2009 - Patient Safety. July 15, 2009 Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I. https://psnet.ahrq.gov/issue/patient-safety-7 This government report analyzes the National Health Service's efforts to enhance patient safety…

4816. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34023/psn-pdf
      April 12, 2008 - Safety in Critical Care Medicine. April 12, 2008 Fein AM, Heffner JE, eds. Crit Care Clin. 2005;21(1):1-176. https://psnet.ahrq.gov/issue/safety-critical-care-medicine Recognizing the complexity of the critical care environment, the editors provide access to expert thought in this special issue. Topics covered inc…

4817. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36603/psn-pdf
      November 01, 2012 - Technological methods used to prevent errors aren't infallible. November 1, 2012 Santell JP. Technological methods used to prevent errors aren't infallible. Mater Manag Health Care. 2006;15(12):26-30. https://psnet.ahrq.gov/issue/technological-methods-used-prevent-errors-arent-infallible The author discusses the …

4818. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38924/psn-pdf
      September 09, 2009 - Identifying vulnerabilities in communication in the emergency department. September 9, 2009 Redfern E, Brown R, Vincent C. Identifying vulnerabilities in communication in the emergency department. Emerg Med J. 2009;26(9):653-7. doi:10.1136/emj.2008.065318. https://psnet.ahrq.gov/issue/identifying-vulnerabilities-c…

4819. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38244/psn-pdf
      November 26, 2008 - Event reporting: the value of a nonpunitive approach. November 26, 2008 Youngberg BJ. Event reporting: the value of a nonpunitive approach. Clin Obstet Gynecol. 2008;51(4):647- 55. doi:10.1097/GRF.0b013e3181899a05. https://psnet.ahrq.gov/issue/event-reporting-value-nonpunitive-approach This article discusses ways …

4820. 5Admiss (pdf file)
      hcup-us.ahrq.gov/reports/natstats/5admiss.pdf
      February 11, 2011 - Infant Birth (Liveborn) Coronary Atherosclerosis Pneumonia Congestive Heart Failure Heart Attack 3.8 million 1.4 million 1.2 million 990,000 744,000 Top Five Reasons for Hospital Admission Source: Most Common Diagnoses and Procedures in U.S. Community Hospitals, 1996. Healthcare Cost and Utilization Project,…