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Showing results for "failures".

9301. Evidence-based Practice Center Systematic Review Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/diabetes-update-2015_disposition-comments.pdf
      January 01, 2015 - Evidence-based Practice Center Systematic Review Protocol Source: https://www.effectivehealthcare.ahrq.gov/ search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=2207 Published Online: April 19, 2016 Comparative Effectiveness Review Disposition of Comments Report Research Review Title: Dia…

9302. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
      January 01, 2019 - Network of Patient Safety Databases Chartbook, 2019 Network of Patient Safety Databases Chartbook, 2019 This document is in the public domain and may be used and reprinted without permission. Citation of the source is appreciated. Suggested citation: Network of Patient Safety Databases Chartbook, 2019. Rockvi…

9303. Appendix D to the Final Report Barriers to Meaningful Use in Medicaid: Analysis and Recommendations (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixD.pdf
      October 31, 2013 - Costs (financial and otherwise) – Lack of leadership – Risks – Organizational culture – Past failures

9304. Appendix E to the Final Report Barriers to Meaningful Use in Medicaid: Analysis and Recommendations (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixE.pdf
      October 31, 2013 - Costs (financial and otherwise) – Lack of leadership – Risks – Organizational culture – Past failures

9305. Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide1.html
      October 01, 2017 - We understand that even small failures in safety protocols can lead to catastrophic or adverse events

9306. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867805/psn-pdf
      February 26, 2025 - have noted is that variation in how well hospitals prevent falls or pressure injuries suggests that failures

9307. Removing Insult from Injury—Disclosing Adverse Events | PSNet
      psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
      February 01, 2006 - that they can report their errors so risk management can look into the organization's latent system failures

9308. Difficult Encounters: A CMO and CNO Respond | PSNet
      psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
      March 01, 2018 - 12, 2019 Failure to debrief after critical events in anesthesia is associated with failures

9309. In Conversation with…John Banja, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
      February 01, 2006 - that they can report their errors so risk management can look into the organization's latent system failures

9310. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73153/psn-pdf
      April 28, 2021 - The second case illustrates the consequences of process failures when multiple errors occur, undesigned

9311. Patient and Family Engagement | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
      September 01, 2013 - The Second Victim: Health Care Workers 7 Say: Adverse events are often system failures.

9312. 009-Antibiotic-Stewardship-Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/009-antibiotic-stewardship-guide.docx
      October 01, 2024 - Slide 6 Antibiotic Exposure and MRSA Risk SAY: Although failures of infection control practices are

9313. Module 1: Preventing Pressure Injuries in Hospitals (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange.docx
      July 12, 2017 - We understand that even small failures in safety protocols can lead to catastrophic or adverse events

9314. How are CHIPRA quality demonstration States improving perinatal care? | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight12.html
      May 01, 2015 - health care, such as cesarean births among low-risk women, nonmedically indicated inductions, induction failures

9315. Final Progress Report: Systems Approach for Improving Region-Wide Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
      January 01, 2024 - Types of system failures that have been identified include inadequate adverse outcome reporting systems

9316. In Conversation With… Maureen Bisognano | PSNet
      psnet.ahrq.gov/perspective/conversation-maureen-bisognano
      February 26, 2025 - Those failures then add up.

9317. Advancing Patient Safety Through Diagnostic Excellence (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-diagnostic-excellence-webinar.pdf
      June 01, 2025 - patient-provider communication and mitigating pitfalls in the diagnostic process related to communication failures

9318. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33857/psn-pdf
      July 01, 2012 - more and more to consumer-mediated exchange as a way to get past those disincentives, those market failures

9319. Section 1: Planning a Care Management Program | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm1.html
      October 01, 2014 - Build on Lessons Learned from Other States State staff can learn from successes and "productive failures

9320. Appendix: State Overviews | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/tap.html
      October 01, 2014 - care management, and through their openness and willingness to share lessons learned and productive failures