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Showing results for "failures".

5781. Discharge Fumbles | PSNet
      psnet.ahrq.gov/web-mm/discharge-fumbles
      September 09, 2009 - SPOTLIGHT CASE Discharge Fumbles Citation Text: Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

5782. Statistical Brief #6: Hospitalizations in the Elderly Population, 2003 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb6.pdf
      May 01, 2006 - Statistical Brief #6: Hospitalizations in the Elderly Population, 2003 HEALTHCARE COST AND UTILIZATION PROJECT Agen Res 6 May 2006 Althou only 1 popula accou hospit over 1 Hospit resulte totalin 43.6 p hospit Hospit elderly higher hospit elderly elderly origina depart propor died d …

5783. Statistical Brief #6
      hcup-us.ahrq.gov/reports/statbriefs/sb6.jsp
      May 01, 2006 - Statistical Brief #6 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs Email Updates …

5784. Making Healthcare Safer (MHS) IV: Patient Monitoring Systems to Prevent Failure to Rescue | Effective Health Care (EHC) Program
      effectivehealthcare.ahrq.gov/products/patient-monitoring-systems/protocol

5785. Development of Statistical Estimators to Address Questions of Comparative Effectiveness in Elderly Heart Failure Patients | Effective Health Care (EHC) Program
      effectivehealthcare.ahrq.gov/products/heart-failure-seniors-estimators/research

5786. Risk Management and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/risk-management-and-patient-safety
      December 01, 2010 - This coding and analysis allows RMF to identify patterns of errors and of systems failures (e.g., lack … 2006, which identified and analyzed patterns of risk factors in several key areas including diagnostic failures

5787. In Conversation with...Geri Amori, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
      December 01, 2010 - This coding and analysis allows RMF to identify patterns of errors and of systems failures (e.g., lack … 2006, which identified and analyzed patterns of risk factors in several key areas including diagnostic failures

5788. What Do We Know About Emergency Department Safety? | PSNet
      psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
      June 01, 2010 - theme is getting your colleagues and yourself to be comfortable learning about and hearing about your failures … To be frank with people and let them know what's coming and the sorts of failures that they're going

5789. In Conversation with David W. Bates about Are We Safer Today? | PSNet
      psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
      February 26, 2025 - have noted is that variation in how well hospitals prevent falls or pressure injuries suggests that failures … The commentaries call out a lack of national reporting on preventable harm and failures to spread promising

5790. Are We Safer Today? | PSNet
      psnet.ahrq.gov/perspective/are-we-safer-today
      February 26, 2025 - The commentaries call out a lack of national reporting on preventable harm and failures to spread promising … have noted is that variation in how well hospitals prevent falls or pressure injuries suggests that failures

5791. Optimize Briefings and Debriefings: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
      December 01, 2017 - By reflecting on how well teams work together, the team can then articulate successes and failures. … Slide 12: Root Causes of Sentinel Events in 2013 Say: Communication failures across the health

5792. Facilitator Guide: Optimize Your Briefings and Debriefings (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings_facnotes.docx
      December 01, 2017 - By reflecting on how well teams work together, the team can then articulate successes and failures. … Slide 11 Root Causes of Sentinel Events in 2013 SAY: Communication failures across the health care

5793. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
      January 01, 2002 - involvement of physicians in most financial decisions” (1.8), “there is open discussion of clinical failures … There is an open discussion of clinical failures. 1.9 (0.8) * In response to the question, “To what

5794. Serious Reportable Adverse Events in Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
      December 01, 2000 - when an event occurs, it should be investigated to determine the underlying system problems and/or failures … improve safety if the lessons learned from their investigations of the underlying system problems and/or failures

5795. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867379/psn-pdf
      January 01, 2025 - Implementation of electronic triggers to identify diagnostic errors in emergency departments. December 18, 2024 Vaghani V, Gupta A, Mir U, et al. Implementation of electronic triggers to identify diagnostic errors in emergency departments. JAMA Intern Med. 2025;185(2):143-151. doi:10.1001/jamainternmed.2024.6214. …

5796. Table 27. Utilization of education and case management (ECM) visits among adults with diabetes or cardiovascular disease by patient characteristics. All project sites. Fisca | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chap6tab27.html
      December 01, 2017 - Table 27. Utilization of education and case management (ECM) visits among adults with diabetes or cardiovascular disease by patient characteristics. All project sites. Fisca ARRA Grant Initiative Findings from a set of 16 grants on improving delivery systems and on spreading evidence-based practices through d…

5797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43664/psn-pdf
      September 01, 2016 - Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. September 1, 2016 Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive ob…

5798. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38941/psn-pdf
      November 25, 2009 - Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety. November 25, 2009 Tjia J, Mazor KM, Field T, et al. Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety. J Patient Saf. 2009;5(3):145-152. doi:10.10…

5799. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43280/psn-pdf
      November 30, 2016 - Medical Office Survey on Patient Safety Culture: 2014 User Comparative Database Report. November 30, 2016 Sorra J, Famolaro T, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. Report No. 14-0032-EF. https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture-2014…

5800. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38411/psn-pdf
      December 16, 2014 - A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. December 16, 2014 Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-87. https://psnet.ahrq.gov/issue/reengine…