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Showing results for "failures".

9101. Final Progress Report: REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/oleary-report.pdf
      January 01, 2024 - climate and collaboration is similar to prior studies of similar interventions.16, 17 Communication failures … Communication failures: an insidious contributor to medical mishaps.

9102. 7.  Appendix C: Additional Tables by Topic Area | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-c.html
      May 01, 2024 - Brigham and Women’s Hospital; Independent Hospital Develops a Diagnostic Center of Excellence to reduce failures … Brigham and Women’s Hospital; Independent Hospital Develops a Diagnostic Center of Excellence to reduce failures

9103. Data Evaluation of All-Payer Claims Databases | Agency for Healthcare Research and Quality
      www.ahrq.gov/data/apcd/backgroundrpt/data.html
      April 01, 2017 - This situation can occur due to carve-outs, multiple coverage for one individual, duplicate claims, or failures

9104. Evidence-based Contingency Planning for Electronic Health Record Downtime - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs024350-wernz-final-report-2018.pdf
      January 01, 2018 - Internal and unexpected downtime events can be caused by EHR system failures, or software and hardware

9105. TeamSTEPPS® Diagnosis Improvement: Diagnostic Journey of Mr. Kane (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-presenter-notes.pdf
      June 02, 2025 - The story outlines several areas where communication failures led to missed and delayed diagnosis that

9106. Journey of Mr. Kane
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-mr-kane.pptx
      June 02, 2025 - The story outlines several areas where communication failures led to missed and delayed diagnosis that

9107. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33787/psn-pdf
      January 01, 2018 - Those failures then add up.

9108. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843150/psn-pdf
      December 05, 2022 - often hold a lot of tension in our bodies when we are uncomfortable, whether it is because of our own failures

9109. Chapter 1. The Framework for Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide1.html
      February 01, 2016 - multifaceted interventions to reinforce and integrate the protocol into practice, addressing weak links and failures

9110. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. | PSNet
      psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
      November 25, 2020 - alarm-related sentinel events including alarm fatigue (most common), as well as equipment malfunctions/failures

9111. Chapter 1. The Framework for Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide1.html
      February 01, 2016 - multifaceted interventions to reinforce and integrate the protocol into practice, addressing weak links and failures

9112. Strategies for Improving Patient Experience with Ambulatory Care: On-Demand Advice, Diagnosis, and Treatment for Minor Health Conditions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6f.pdf
      March 01, 2017 - Stress in telephone helpline nurses is associated with failures of concentration, attention and memory

9113. Using Barcode Medication Administration to Improve Quality and Safety (pdf file)
      digital.ahrq.gov/sites/default/files/docs/lesson/09-0023-ef-bcma.pdf
      December 01, 2008 - Findings The grantee interviews provided detailed information about the successes, failures

9114. AHRQ Stats | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/ahrq-stats.html
      July 01, 2025 - AHRQ Stats New data nuggets from AHRQ News Now posted weekly to highlight AHRQ statistical reports on health care trends. Adverse Drug Events Involving Hypoglycemic Agents In 2021, 7.5 percent of Hispanic patients, 6.6 percent of Black patients, 6.2 percent of patients with an “other” or unknown race, and 4.0…

9115. Using Health IT Chronic Disease Management (pdf file)
      digital.ahrq.gov/sites/default/files/docs/hit-cdm-transcript-062111.pdf
      June 16, 2021 - Using Health IT Chronic Disease Management ______________________________________________________________________________________ Using Health IT for Chronic Disease Management Page 1 of 22 NATIONAL WEB-BASED TELECONFERENCE ON HEALTH IT: USING HEALTH IT FOR CHRONIC DISEASE MANAGEMENT ________…

9116. Chartbook on Black Health Care: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/qdr-blackhealth-slides.html
      November 01, 2020 - Chartbook on Black Health Care: Slide Presentation National Healthcare Quality and Disparities Report Contents Introduction Part 1: Overviews of the Report and the Black Population Part 2: Trends in Priorities of the Heckler Report Part 3: Trends in Access and Priorities of the National Quality Strate…

9117. Aspirin or Nonsteroidal Anti-inflammatory Drugs for the Primary Prevention of Colorectal Cancer (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/c-7ARQE9RuXKjjpeLABkaH
      March 01, 2007 - Aspirin or Nonsteroidal Anti-inflammatory Drugs for the Primary Prevention of Colorectal Cancer Routine Aspirin or Nonsteroidal Anti-inflammatory Drugs for the Primary Prevention of Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement U.S. Preventive Services Task Force* This statement sum…

9118. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet
      psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
      July 01, 2011 - SPOTLIGHT CASE Spotlight: Mistaken Attribution, Diagnostic Misstep Citation Text: Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citat…

9119. Suppl-2-User-Guide-To-Ocer 130129 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/suppl-2-user-guide-to-ocer_130129.pdf
      January 01, 2011 - 177 Abstract This supplement describes how counterfactual theory is used to define causal effects and the conditions in which observed data can be used to estimate counterfactual-based causal effects. Basic definitions and language used in causal graph theory are then presented. The graphical separation rules linki…

9120. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet
      psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
      March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…