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Showing results for "failures".

8841. ED Disability Diagnostic Tool: An HIT Feasibility Study | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/ed-disability-diagnostic-tool-hit-feasibility-study
      January 01, 2023 - ED Disability Diagnostic Tool: An HIT Feasibility Study Project Final Report ( PDF , 218.58 KB) 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 represent the views of AHR…

8842. Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. | PSNet
      psnet.ahrq.gov/issue/antecedent-treat-and-release-diagnoses-prior-sepsis-hospitalization-among-adult-emergency
      May 12, 2021 - Study Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. Citation Text: Nassery N, Horberg MA, …

8843. Fact Sheet on Pediatric Quality Indicators (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1c_combo_pdifactsheet.pdf
      October 01, 2015 - Fact Sheet on Pediatric Quality Indicators Toolkit for Using the AHRQ Quality Indicators How To Improve Hospital Quality and Safety 1 Tool A.1c Fact Sheet on Pediatric Quality Indicators What Are the Pediatric Quality Indicators (PDIs)? The Pediatric Quality Indicators (PDIs) are a set of 16 measures (15 st…

8844. Education outcomes from a duty-hour flexibility trial in internal medicine. | PSNet
      psnet.ahrq.gov/issue/education-outcomes-duty-hour-flexibility-trial-internal-medicine
      December 12, 2012 - Study Classic Education outcomes from a duty-hour flexibility trial in internal medicine. Citation Text: Desai SV, Asch DA, Bellini LM, et al. Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine. New Engl J Med. 2018;378(16):1494-1508. doi:1…

8845. Penicillin Allergy (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/penicillin-allergy-one-pager.pdf
      September 01, 2022 - Penicillin Allergy Penicillin Allergy Importance of documenting an accurate allergy history • About 10 percent of people in the United States report an allergy to penicillin, but at least 95 percent of them can safely tolerate beta-lactam antibiotics—penicillins and cephalosporins.1 • Inaccurate…

8846. What Is the Role of the PSO Authorized Official? (pdf file)
      pso.ahrq.gov/sites/default/files/wysiwyg/what-is-the-role-of-ao.pdf
      July 01, 2021 - What Is the Role of the PSO Authorized Official? WHAT IS THE ROLE OF THE PSO AUTHORIZED OFFICIAL? Establishing an “Authorized Official” When an entity seeks listing as a PSO, it must identify an individual with authority to make commitments on behalf of the entity—referred to as “Authorized Official” or AO—to co…

8847. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. | PSNet
      psnet.ahrq.gov/issue/good-care-slow-enough-be-able-pay-attention-primary-care-time-scarcity-and-patient-safety
      August 04, 2015 - Study "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. Citation Text: Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. J Gen Intern …

8848. Patient-related factors associated with an increased risk of being a reported case of preventable harm in first-line health care: a case-control study | PSNet
      psnet.ahrq.gov/issue/patient-related-factors-associated-increased-risk-being-reported-case-preventable-harm-first
      October 09, 2019 - Study Patient-related factors associated with an increased risk of being a reported case of preventable harm in first-line health care: a case-control study Citation Text: Fernholm R, Holzmann MJ, Wachtler C, et al. Patient-related factors associated with an increased risk of being a rep…

8849. Patient Safety Organization: Two Bona Fide Contracts Requirement (pdf file)
      pso.ahrq.gov/sites/default/files/wysiwyg/PSO_BonaFideContracts.pdf
      September 30, 2024 - Patient Safety Organization: Two Bona Fide Contracts Requirement …

8850. Mod4-System-Focused-Event-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
      April 01, 2016 - Purpose: To help teams adopt a system-focused approached to event investigation and analysis. Who should use this tool? Event Reporting, Investigation, and Analysis Team. How to use this tool: Review the guide information when developing and implementing a systems approaching to event investigation and analysis. T…

8851. Evidence-based Practice Center Systematic Review Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/health-literacy_research-protocol.pdf
      January 22, 2010 - Evidence-based Practice Center Systematic Review Protocol Source: www.effectivehealthcare.ahrq.gov Published Online: January 22, 2010 1 Evidence-based Practice Center Systematic Review Protocol Project Title: Health Literacy Interventions and Outcomes: An Update of the Literac…

8852. Individualized Plans of Care to Improve Outcomes Among Children and Adults With Chronic Illness: A Systematic Review (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/Lion-Mangione-Britto.pdf
      October 01, 2011 - Individualized Plans of Care to Improve Outcomes Among Children and Adults With Chronic Illness: A Systematic Review Individualized Plans of …

8853. Hcup Formats
      hcup-us.ahrq.gov/db/tools/HCUP_Formats.TXT
      December 28, 2023 - /* ============================================================================= Program : HCUP_Formats.txt …

8854. Improving Communication and Teamwork in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
      May 01, 2017 - Communication failures are a frequent cause of patient harm. … Studies have found that communication failures are the cause of up to 80 percent of operating room adverse

8855. Final Progress Report: Videotaping communication between physicians and nurses: A methods study (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/manojlovich-report.pdf
      January 01, 2024 - Communication failures: An insidious contributor to medical mishaps.

8856. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74121/psn-pdf
      November 30, 2021 - alarm-related sentinel events including alarm fatigue (most common), as well as equipment malfunctions/failures

8857. Cusp Patient Family Engagement Facilitator Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP_Patient_Family_Engagement_Facilitator_Notes.docx
      June 02, 2025 - Slide 25 SAY: Adverse events are often system failures.

8858. Improving Communication and Teamwork in the Surgical Environment
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving.pptx
      May 01, 2017 - and Teamwork | ‹#› AHRQ Safety Program for Ambulatory Surgery 6 Studies show that communication failures

8859. Central Venous Catheter Insertion Bundle Facilitator Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-insertion-notes.docx
      April 01, 2022 - · According to the Centers for Disease Control and Prevention, communication failures may account for

8860. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49681/psn-pdf
      April 01, 2013 - As occurred in this case, multiple failures across the PN-use process are usually identified in retrospect