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psnet.ahrq.gov/issue/improving-team-members-attention-during-or-briefing-or-time-out
November 10, 2021 - Study
Improving team members' attention during the OR briefing or time out.
Citation Text:
Braverman A. Improving team members' attention during the OR briefing or time out. AORN Journal. 2024;119(6):421-427. doi:10.1002/aorn.14144.
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DOI Google Scholar …
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psnet.ahrq.gov/issue/safety-ii-and-study-healthcare-safety-routines-two-paths-forward-research
May 25, 2022 - Commentary
Safety-II and the study of healthcare safety routines: two paths forward for research.
Citation Text:
Rydenfält C. Safety-II and the study of healthcare safety routines: two paths forward for research. J Patient Saf Risk Manag. 2022;27(3):124-128. doi:10.1177/25160435221102129…
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psnet.ahrq.gov/issue/good-and-bad-reasons-swiss-cheese-model-and-its-critics
September 14, 2022 - Commentary
Classic
Good and bad reasons: the Swiss cheese model and its critics.
Citation Text:
Larouzee J, Le Coze J-C. Good and bad reasons: the Swiss cheese model and its critics. Safety Sci. 2020;126:104660. doi:10.1016/j.ssci.2020.104660.
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www.ahrq.gov/ncepcr/tools/pf-handbook/mod5-appendix.html
March 01, 2022 - Role ambiguity.
Duplicated efforts.
Unnecessary steps.
Sources of waste.
Variation.
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psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
May 21, 2019 - Commentary
Classic
The collapse of sensemaking in organizations: the Mann Gulch disaster.
Citation Text:
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q. 2006;38(4):628-652. doi:10.2307/2393339.
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www.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
August 01, 2022 - AHRQ Views: Blog posts from AHRQ leaders
AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors
AUG
22
2022
By
Robert Otto
Valdez,
Ph.D., M.H.S.A.
R. Valdez, Ph.D., M.H.S.A.
Too many Americans have experienced the health-related consequences and anxieties that f…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/assertion-slides/Assertion-Dec-14-2010-508.ppt
January 01, 2010 - On the CUSP: Stop BSI
On the CUSP: Stop BSI
Appropriate Assertion
David Thompson, DNSc, MS, RN
Jill Marsteller, PhD, MPP
Department of Anesthesiology and Critical Care Medicine
The Johns Hopkins Quality and Safety Research Group
*
Communication Styles
Assertive
Aggressive
Passive or Passive Aggressive ?
© 2004…
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psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and
September 25, 2024 - Study
Classic
Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error.
Citation Text:
Edmondson AC. Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences o…
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - TeamSTEPPS recommends the “Concern-Uncomfortable-Safety Event” (CUS) technique to
minimize ambiguity
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www.ahrq.gov/prevention/resources/chronic-care/ccrm-atlas-suppl/ccrm-atlas2.html
October 01, 2020 - Potential Measures for Clinical-Community Relationships
Potential Measure Development Methodology
Previous Page Next Page
Table of Contents
Potential Measures for Clinical-Community Relationships
Acknowledgements
Executive Summary
Introduction
Potential Measure Development Methodology
Pote…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/develop/develop.doc
January 01, 2003 - If customized specifications introduce vagueness or ambiguity, precision is lost and both comparability
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www.ahrq.gov/patient-safety/resources/vtguide/appb.html
May 01, 2016 - Operational definition of “expected LOS <48 hours” calls for judgment and could lead to ambiguity (e.g … Operational definition of "expected LOS <48 hours" calls for judgment and could lead to ambiguity.
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psnet.ahrq.gov/issue/adequacy-information-transferred-resident-sign-out-hospital-handover-care-prospective-survey
April 30, 2008 - Study
Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey.
Citation Text:
Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al. Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective …
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psnet.ahrq.gov/issue/measuring-teamwork-health-care-settings-review-survey-instruments
December 14, 2016 - Review
Measuring teamwork in health care settings: a review of survey instruments.
Citation Text:
Valentine MA, Nembhard IM, Edmondson A. Measuring teamwork in health care settings: a review of survey instruments. Med Care. 2015;53(4):e16-e30. doi:10.1097/MLR.0b013e31827feef6.
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module3.pptx
January 01, 2008 - Accountability: You are accountable until both parties are aware of the transfer
Uncertainty: Clear up all ambiguity … When uncertainty exists, it is your responsibility to clear up all ambiguity of responsibility before
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module3.pptx
January 01, 2008 - Accountability: You are accountable until both parties are aware of the transfer
Uncertainty: Clear up all ambiguity … When uncertainty exists, it is your responsibility to clear up all ambiguity of responsibility before
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module3.pptx
January 01, 2008 - Accountability: You are accountable until both parties are aware of the transfer
Uncertainty: Clear up all ambiguity … When uncertainty exists, it is your responsibility to clear up all ambiguity of responsibility before
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module3.pptx
January 01, 2008 - Accountability: You are accountable until both parties are aware of the transfer
Uncertainty: Clear up all ambiguity … When uncertainty exists, it is your responsibility to clear up all ambiguity of responsibility before
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module3.pptx
January 01, 2008 - Accountability: You are accountable until both parties are aware of the transfer
Uncertainty: Clear up all ambiguity … When uncertainty exists, it is your responsibility to clear up all ambiguity of responsibility before
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module3.pptx
January 01, 2008 - Accountability: You are accountable until both parties are aware of the transfer
Uncertainty: Clear up all ambiguity … When uncertainty exists, it is your responsibility to clear up all ambiguity of responsibility before