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Total Results: over 10,000 records

Showing results for "failures".

6801. Patient Safety Concerns and the LGBTQ Population | PSNet
      psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population
      February 01, 2023 - often hold a lot of tension in our bodies when we are uncomfortable, whether it is because of our own failures … Perspectives on Safety Annual Perspective Impact of System Failures

6802. Maternal Safety and Perinatal Mental Health | PSNet
      psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
      March 28, 2023 - Perinatal Care, which is focused on improving labor and delivery communication and avoiding system failures … Perspectives on Safety Annual Perspective Impact of System Failures

6803. Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - Perspectives on Safety Annual Perspective Impact of System Failures … Perspectives on Safety Annual Perspective Impact of System Failures

6804. Final Progress Report: What Is Patient Safety in the Medical Home? (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/dy-report.pdf
      January 01, 2024 - outdated/incorrect diagnoses Lack of time to collect and synthesize patient information Communication failures … both clinicians, staff and patients as perceived causes of safety issues also included communication failures

6805. Final Progress Report: Risk-Informed Intervention to Improve Ambulatory Drug Monitoring and Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/field-report.pdf
      January 01, 2024 - intervention points, we performed qualitative review of the fault trees and cut sets to understand failures … We found that the failures were primarily a product of the lack of redundancy and missing communication

6806. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
      December 01, 2017 - Finally, individual patient characteristics can and do contribute to system failures. … When evaluating the defect as a system issue, we find many systems failures in the knowledge, skills,

6807. The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Phillips.pdf
      January 01, 2004 - not arising from an error, 283 (83 percent) were of mistakes in care arising from system and process failures … nonpunitive culture for reporting health care errors that focuses on preventing and correcting systems failures

6808. CER 221 Disposition of Comments: Pharmacologic and Nonpharmacologic Therapies in Adult Patients With Exacerbation of COPD (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-221-copd-comments_0.pdf
      October 11, 2019 - Peer reviewer #1 Results In the Results section you separate cure rates from failures.

6809. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report.pdf
      January 01, 2022 - Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 This page intentionally left blank. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 Authors: David Rodrick, Andrea Ti…

6810. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
      January 01, 2022 - Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report PATIENT SAFETY e Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 Preliminary Report This page intentionally left blank. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022:…

6811. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
      January 01, 2022 - Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 PATIENT SAFETY e This page intentionally left blank. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 Authors: David Rodrick, Ph.D.; Andre…

6812. 2015-04 (pdf file)
      hcup-us.ahrq.gov/reports/methods/2015-04.pdf
      January 01, 2015 - 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 with HCUP Products: Email: hcup@ahrq.gov or Phone: 1-866-29…

6813. Implementation Guide for Enhancing Care Coordination for Cardiac Rehabilitation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/care-coordination-implementation-guide.pdf
      March 01, 2023 - Discuss struggles and failures with a focus on learning and improvement.

6814. Making Information Technology a Team Player in Safety: The Case of Infusion Devices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Nemeth.pdf
      January 01, 2002 - In spite of technological progress in the practice of infusions, failures and adverse events are plentiful

6815. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866055/psn-pdf
      May 29, 2024 - exploration; 2) a surgical debrief; 3) a visual counter; 4) imaging; and if needed, 5) the reporting of failures

6816. Impatient Inpatient Dosing | PSNet
      psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
      June 24, 2020 - 27, 2020 Preventing adverse events caused by emergency electrical power system failures

6817. Moving Pains | PSNet
      psnet.ahrq.gov/web-mm/moving-pains
      August 17, 2017 - Administrators Critical Care Discontinuities, Gaps, and Hand-Off Problems Monitoring Errors and Failures

6818. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865455/psn-pdf
      March 27, 2024 - topic may explore Safety II approaches, which seek to understand safety through successes rather than failures

6819. Crossing the Line | PSNet
      psnet.ahrq.gov/web-mm/crossing-line
      December 01, 2012 - Complications and failures of subclavian-vein catheterization.

6820. Appendix F to the Final Report Barriers to Meaningful Use in Medicaid: Analysis and Recommendations (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixF.pdf
      October 31, 2013 - – Costs (financial & other) – Lack of leadership – Risks – Organizational culture – Past failures