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Showing results for "failures".

501. 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

502. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.monahrq.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

503. Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice. | PSNet
     psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line
     May 24, 2016 - From the Same Author(s) Work Design Drivers of Organizational Learning about Operational Failures … July 8, 2016 Work Design Drivers of Organizational Learning about Operational Failures

504. High reliability: excellent care every time. | PSNet
     psnet.ahrq.gov/issue/high-reliability-excellent-care-every-time
     July 19, 2018 - June 10, 2018 Reducing interdisciplinary communication failures through secure text messaging … August 12, 2015 Inquiry into reporter's death finds multiple failures in care.

505. 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

506. 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

507. 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

508. Chapter 2. What is Care Coordination? | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.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

509. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
     psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
     August 01, 2009 - There's bank failures, corporate failures in the auto industry, and health care. … More importantly, operational failures disrupt patient care, leading to uncompleted tasks and medical … Identification of systems failures in successful paediatric cardiac surgery. … The impact of operational failures on hospital nurses and their patients. … Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41:643-662.

510. Governing the surgical count through communication interactions: implications for patient safety. | PSNet
     psnet.ahrq.gov/issue/governing-surgical-count-through-communication-interactions-implications-patient-safety
     November 06, 2015 - RIS Download Citation Related Resources From the Same Author(s) Failures … October 11, 2023 Operational failures detected by frontline acute care nurses.

511. Management of the difficult airway: a closed claims analysis. | PSNet
     psnet.ahrq.gov/issue/management-difficult-airway-closed-claims-analysis
     July 13, 2010 - July 13, 2010 Communication failures contributing to patient injury in anaesthesia malpractice … February 8, 2023 Communication failures contributing to patient injury in anaesthesia

512. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49814/psn-pdf
     December 01, 2017 - web-mm/miscommunication-or-leads-anticoagulation-mishap As highlighted by this case, communication failures … In one study exploring OR communication failures, researchers found that they were present in approximately … optimal safety culture is challenging: no single intervention can address all communication-related failures … Communication failures in the operating room: an observational classification of recurrent types and … Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186-194.

513. 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

514. Cardio-HIT Phase II - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/r18hs017160-kmetik-final-report-2009.pdf
     January 01, 2009 - study designed to investigate the prevalence and patterns of rates of exceptions, apparent quality failures … The calculation was performed separately on the number of measure failures and the number of exceptions … of identified failures that were true failures was within 5% of the same proportion among the entire … For these measures, quality failures would have been overestimated were reporting of exceptions not … Our finding that approximately 75% of cases considered apparent quality failures by automatic query

515. 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

516. Getting Started Laying the Groundwork Coordination for Implementing Automatic Referral & Effective Care
     ce.effectivehealthcare.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

517. 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.

518. 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.

519. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     ce.effectivehealthcare.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.

520. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - Background: Reviews of recent research-related fatalities have demonstrated that clinical research system failures … : Collecting research unit-specific information on potential safety concerns could identify system failures … Typically the same system failures that might have resulted in an injury also are present in a near … However, these latent failures serve as “holes” in the usual safety mechanisms. … Other novel methods to identify and mange potential system failures in clinical research need to be