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Showing results for "failures".

  1. 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

  2. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet

    psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
    September 25, 2019 - WebM&M Cases Delay in Malignancy Diagnosis Reflects Systemic Failures

  3. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet

    psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
    July 23, 2024 - exploration; 2) a surgical debrief; 3) a visual counter; 4) imaging; and if needed, 5) the reporting of failures

  4. PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-implementation-slides.pptx
    June 02, 2025 - Thrive in a culture that punishes individuals for systemic failures.

  5. Mobile Patient-Reported Outcomes for Value and Effectiveness (mPROVE) - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/u18hs026883-jih-final-report-2024.pdf
    January 01, 2024 - The most time- consuming errors to fix were periodic, iOS failures that resulted in the iOS version of

  6. 2. Description of the Intervention | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreen2.html
    April 01, 2018 - Finally, since "failures to inform patients or to document informing patients of abnormal outpatient

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866826/psn-pdf
    September 25, 2024 - Despite the multiple safety features on anesthesia machines to prevent cross- connection, rare safety failures

  8. Making Healthcare Safer IV: Supply Chain Disruption Monitoring Programs (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/monitoring-programs-protocol.pdf
    January 01, 2024 - Causes and consequences of medical product supply chain failures.

  9. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care | PSNet

    psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
    June 01, 2003 - "holes" in nurse staffing are allowed to remain unfilled at times like these, my guess is that such failures

  10. MAINTAIN AND EXPAND (pdf file)

    hcup-us.ahrq.gov/reports/methods/EvalofSASD1999Final.pdf
    June 13, 2003 - Some differences may stem from failures to match facilities in the AHA data to facilities in the SMG

  11. Co-producing a Diagnosis

    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/09-diagnostic-safety-practice-orientation.pptx
    November 24, 2020 - patient-provider communication and mitigating pitfalls in the diagnostic process related to communication failures

  12. Layout 1 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/gerd-2005_executive.pdf
    January 01, 2005 - Layout 1 Background Gastroesophageal reflux disease (GERD), defined as weekly heartburn and/or acid regurgitation, is one of the most common health conditions affecting older Americans. Direct costs attributable to GERD were estimated to be $10 billion in the United States in 2000. Some patients have frequent, sever…

  13. Coming Up Short: Maintaining Safety in the Face of Drug Shortages | PSNet

    psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
    November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages Citation Text: Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …

  14. Most Common Diagnoses and Procedures in U.S. Community Hospitals, 1996

    hcup-us.ahrq.gov/reports/natstats/commdx/table1c.htm
    February 11, 2011 - Most Common Diagnoses and Procedures in U.S. Community Hospitals, 1996 Table 1 (continued). The top 100 principal procedures and their associated principal diagnoses: HCUP Nationwide Inpatient Sample, 1996 -------------------------------------------------------------------------------------------------------…

  15. Most Common Diagnoses and Procedures in U.S. Community Hospitals, 1996

    hcup-us.ahrq.gov/reports/natstats/commdx/table1g.htm
    February 11, 2011 - Most Common Diagnoses and Procedures in U.S. Community Hospitals, 1996 Table 1 (continued). The top 100 principal procedures and their associated principal diagnoses: HCUP Nationwide Inpatient Sample, 1996 -------------------------------------------------------------------------------------------------------…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33751/psn-pdf
    January 01, 2014 - Strengthening the Business Case for Patient Safety May 1, 2013 Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety Perspective After more than a decade in the national spotlight, the problem of pati…

  17. Preventable Emergency Department Visits | Agency for Healthcare Research and Quality

    www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure2.html
    June 01, 2018 - Chartbook on Care Coordination Preventable Emergency Department Visits Previous Page Next Page Table of Contents Chartbook on Care Coordination Acknowledgments Care Coordination Trends in Care Coordination Measures Transitions of Care Preventable Emergency Department Visits Potentially A…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49523/psn-pdf
    November 01, 2006 - Urinary Retention Dilemma November 1, 2006 Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma The Case Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy (BPH) and urinary hesitancy returned to th…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49670/psn-pdf
    November 01, 2012 - Missed Pneumonia November 1, 2012 Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/missed-pneumonia The Case A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic chest pain. Review of systems was negative for cough or dy…

  20. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
    January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…
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