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Showing results for "failures".

  1. Approach to Improving Patient Safety: Communication | PSNet

    psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
    August 31, 2020 - burden of gathering key diagnostic information, technical problems, data entry problems, and system failures

  2. Patient Safety 101 | PSNet

    psnet.ahrq.gov/primer/patient-safety-101
    January 16, 2025 - analyzed errors in fields as diverse as aviation and nuclear power—revealed that catastrophic safety failures

  3. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
    September 01, 2016 - culture from one of blaming individuals for errors to one in which errors are treated not as personal failures

  4. Preventing Pressure Injuries in Hospitals

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
    June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes

  5. Chapter 2. Building the Project Foundation: Project Teams and Scope | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/match/chapter-2.html
    July 01, 2022 - Potential failures. Unnecessary redundancies and gaps in the process.

  6. Critical Opportunity Lost | PSNet

    psnet.ahrq.gov/web-mm/critical-opportunity-lost
    February 17, 2017 - WebM&M Cases Delay in Malignancy Diagnosis Reflects Systemic Failures

  7. Strategies for Improving Patient Experience with Ambulatory Care: Reminder Systems for Immunizations and Preventive Services (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-r.pdf
    April 14, 2017 - Does the reminder system meet physicians’ needs while also incorporating safeguards against process failures

  8. AHRQ Safety Program for MRSA Prevention: Targeting SSI

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/125-cusp-science-safety.pptx
    April 01, 2025 - Services The Science of Safety 18 Swiss Cheese Model: How Errors Happen13 Sometimes, the holes (i.e., failures

  9. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)

    pso.ahrq.gov/sites/default/files/wysiwyg/npsdpatient-safety-culture-brief.pdf
    September 01, 2016 - culture from one of blaming individuals for errors to one in which errors are treated not as personal failures

  10. It's All in the Syringe | PSNet

    psnet.ahrq.gov/web-mm/its-all-syringe
    February 01, 2013 - January 6, 2017 Process of care failures in breast cancer diagnosis.

  11. Table of Contents: Volume 1. Assessment (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
    January 01, 2025 - Effects Analysis Based on in Situ Simulations: A Methodology to Improve Understanding of Risks and Failures

  12. Table of Contents: Volume 4. Technology and Medication Safety (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
    January 01, 2025 - Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures

  13. Microsoft Word - QDR 2014 HCUP Short Methods Report_041015_FINAL.docx (pdf file)

    hcup-us.ahrq.gov/reports/methods/2015_02.pdf
    January 01, 2015 - Microsoft Word - QDR 2014 HCUP Short Methods Report_041015_FINAL.docx HCUP Methods Series kbr33831 Contact Information: Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 http://www.hcup-us.ahrq.gov For Technical Assistance…

  14. Evidence Summary - Comparative Effectiveness Review No. 249: Malnutrition in Hospitalized Adults: A Systematic Review (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-249-malnutrition-hospitalized-adults-evidence-summary_0.pdf
    October 01, 2021 - Evidence Summary - Comparative Effectiveness Review No. 249: Malnutrition in Hospitalized Adults: A Systematic Review Comparative Effectiveness Review Number 249 Malnutrition in Hospitalized Adults: A Systematic Review Evidence Summary Main Points • Association Between Malnutrition and Clin…

  15. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
    June 01, 2003 - PowerPoint Presentation Spotlight Case June 2003 Missed Appendicitis webmm.ahrq.gov Source and Credits This presentation is based on June 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: James Adams, MD, Fei…

  16. Evidence Summary - Comparative Effectiveness Review No. 249: Malnutrition in Hospitalized Adults: A Systematic Review (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/cer-249-malnutrition-hospitalized-adults-evidence-summary.pdf
    October 01, 2021 - Evidence Summary - Comparative Effectiveness Review No. 249: Malnutrition in Hospitalized Adults: A Systematic Review Comparative Effectiveness Review Number 249 Malnutrition in Hospitalized Adults: A Systematic Review Evidence Summary Main Points • Association Between Malnutrition and Clin…

  17. Facts and Figures Exhibit 2.2

    hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit2_2.jsp
    January 01, 2007 - Facts and Figures Exhibit 2.2 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …

  18. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James L. Rudolph, MD, SM Editor, AHRQ WebM&M: Robert Wachter, MD Sp…

  19. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
    February 01, 2017 - PowerPoint Presentation Spotlight The Hazards of Distraction: Ticking All the EHR Boxes * Source and Credits This presentation is based on the February 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Anthony C. Easty, PhD, Adjunct Pr…

  20. Event-Summary-Details-Maximizing-Physician-Buy-In (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/event-summary-details-maximizing-physician-buy-in.pdf
    June 16, 2022 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1 AFFINITY GROUP DETAILS AT-A-GLANCE Title Maximizing Physician Support for Cardiac Rehabilitation June 16, 2022 Purpose • To share evidence-based insights and practical solutions that effectively engage with physicians and enc…
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