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monahrq.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
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/readiness/tsreadiness.pdf
August 01, 2005 - Objective information
can originate from a variety of sources, including adverse event and near-miss
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monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-3-readiness-form.pdf
August 01, 2005 - Objective information
can originate from a variety of sources, including adverse event and near-miss
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_slides_fallprev.pptx
June 16, 2017 - understanding that even small failures in safety protocols or processes can lead to catastrophic or adverse … events if action is not taken to solve the problem.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/nurse-role-dxsafety.pdf
September 02, 2022 - Discuss the associated tasks and thought
processes taking place during those events.
4
Domain 3: … SBAR),27-30 to structure communication with physicians and other diagnostic team
members and reduce adverse … events. … in their day-to-day operations.
7
e
Any safety events or “good catches” identified from these … Measure Dx: A Resource To Identify, Analyze, and Learn
From Diagnostic Safety Events. July 2022.
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monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/guide.html
September 01, 2017 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Patients and Families
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events … We understand that even small failures in safety protocols can lead to catastrophic or adverse events
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/trainershandouts_all.pdf
September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more
severe and … professional interpretation services.
3
Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot
study.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/stafftrainhandouts_all.pdf
September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more
severe … professional interpretation services.
3
Hospitals have been held liable for LEP patient safety events … Language proficiency and adverse events in U.S. hospitals: a pilot
study.
-
monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Implement_Hndbook_508.docx
April 30, 2013 - opportunities where they can interact with the health care team
This handout gives information on routine events … One study found that more than 70 percent of adverse events are caused by breakdowns in communication … Communicating to Improve Quality strategy may also help to meet other goals related to patient safety and never events
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monahrq.ahrq.gov/hai/cusp/modules/nursing/nursing-notes.html
December 01, 2012 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … Quality/Safety
Say:
Nurse managers should obtain data on quality outcomes and adverse events monthly
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monahrq.ahrq.gov/funding/process/study-section/prrvmtgs.html
March 01, 2024 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
January 01, 2012 - • Pressure ulcers represent an important patient adverse event that is associated with significant
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monahrq.ahrq.gov/healthsystemsresearch/hspc-research-study/breadth-and-focus.html
July 01, 2021 - Studies
Blog
AHRQ Views
Newsletter
AHRQ News Now
Events … effective strategies to reduce medical errors and harms, such as healthcare-associated infections, adverse … drug events, and preventable hospital readmissions ( Agency for Healthcare Research and Quality, 2018 … the provision of a treatment as appropriate), as well as both intermediate (e.g., disease control, adverse … patient safety events, patient experience) and definitive outcomes of care (e.g., quality of life, mortality
-
monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Implement_Hndbook_508.pdf
April 30, 2013 - where
they can interact
with the health care
team
• This handout gives information on routine events … One study found that more than 70 percent of adverse
events are caused by breakdowns in communication … to Improve Quality strategy may also help to meet other goals
related to patient safety and never events
-
monahrq.ahrq.gov/teamstepps/lep/handouts/lepgoals.html
December 01, 2012 - Studies
Blog
AHRQ Views
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AHRQ News Now
Events
-
monahrq.ahrq.gov/teamstepps/lep/handouts/lepactionplan.html
December 01, 2012 - Studies
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AHRQ Views
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AHRQ News Now
Events
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monahrq.ahrq.gov/teamstepps/instructor/fundamentals/module1/m1evidencebase.html
March 01, 2014 - Studies
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AHRQ Views
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AHRQ News Now
Events … Our iceberg is melting: changing and succeeding under adverse conditions. New York: St.
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monahrq.ahrq.gov/policy/eeo/index.html
February 01, 2024 - Studies
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AHRQ News Now
Events
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monahrq.ahrq.gov/funding/priorities-contacts/special-emphasis-notices/index.html
November 01, 2023 - Studies
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AHRQ News Now
Events
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monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule1.pptx
January 01, 2011 - Washington state, improved the time from decision to the performance of a Caesarean section, with no adverse … Video Discussion
Think about the breakdowns you observed
in the stories:
Can you think of similar events … Of course, you would want to scrub them so that you're only sharing the sequence of events.