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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/instructor_slides/rrsinstructmod.pdf
January 01, 2008 - should be
prioritized based on the risk to patients and on the prevalence and
severity of targeted adverse … events. … •Quality Improvement –
Supports Activators and
Responders by reviewing RRS events and evaluating … During a team huddle,
response team members could:
•Discuss critical issues and emerging events. … and prescribe a course
of action for future events.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
August 01, 2010 - Nurse shift changes require the successful transfer of information between
nurses to prevent adverse … events and medical errors. … One study found that more than 70 percent of adverse events are caused
by breakdowns in communication … on the Centers for Medicare and Medicaid Services’
list of hospital-acquired complications “never events … communication during nurse transitions, for example:
• Reduce the incidence of never events by 5 percent
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigtrainer.pdf
July 01, 2012 - LEP
The Story of Willie Ramirez
SAY:
To illustrate why LEP patients are at risk of patient safety events … Language proficiency and
adverse events in U.S. hospitals: a pilot study. … is inspired by the
2006 book by John Kotter, Our Iceberg Is Melting: Changing and
Succeeding Under Adverse … Our iceberg is melting: changing
and succeeding under adverse conditions. … identified as a primary contributor to the clinical errors
found in malpractice cases and sentinel events
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
August 28, 2012 - ASK:
· How did the pilot CUSP team make a case for their project targeting adverse drug events?
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pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
August 01, 2022 - physician to observe overt and
many times more subtle clues, such as changes in vital signs, sensorium, or events … physician by presenting
a case and receiving feedback.42 The study reported a significant reduction in adverse … events and near-
misses,42 suggesting that distributed cognition played a role by having the physician … Effect of systematic physician cross-checking on reducing adverse events in the emergency
department
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pcmh.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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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/trainershandouts_all.docx
September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more severe and … receive 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.
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/stafftrainhandouts_all.docx
September 01, 2012 - Patient safety events that affect limited-English-proficient (LEP) patients tend to be more severe and … receive 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.
-
pcmh.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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pcmh.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
-
pcmh.ahrq.gov/page/cognitive-task-analysis-methods-improve-patient-centered-medical-home-models-understanding-and
March 01, 2013 - macrocognitive processes include how individuals, teams, and organizations make decisions, make sense of events … CTA methods do exist should the reader wish to investigate the macrocognition of uncommon, critical events … information more comprehensive, organized, and readable, and including decision aids and warnings of adverse … of, what they pay attention to, what options and possibilities they consider, how they make sense of events
-
pcmh.ahrq.gov/teamstepps/instructor/reference/teamperceptionsmanual.html
April 01, 2017 - safety, leadership, interpersonal interactions, attitudes toward stress, and knowledge of how to report adverse … events ( Sexton, et al., 2006 ). … The 50-item T-TPQ was tested and refined during three critical events: cognitive interviews, small group
-
pcmh.ahrq.gov/patient-safety/patients-families/engagingfamilies/index.html
March 01, 2023 - Primary Care Settings
About AHRQ's Quality & Patient Safety Work
Patient Safety News and Events
-
pcmh.ahrq.gov/hai/cusp/modules/spread/notes.html
December 01, 2012 - Ask:
How did the pilot CUSP team make a case for their project targeting adverse drug events?
-
pcmh.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.
-
pcmh.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.
-
pcmh.ahrq.gov/cpi/about/35th-anniversary/index.html
April 01, 2024 - Hospital-Acquired Conditions show that national efforts to reduce hospital-acquired conditions, such as adverse … drug events and injuries from falls, helped prevent an estimated 8,000 deaths and save $2.9 billion
-
pcmh.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.
-
pcmh.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.
-
pcmh.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