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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
April 30, 2022 - Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast
Using TeamSTEPPS and SOPS to Enhance
Surgical Team Communication
Lukasz Mazur, Ph.D.
Division of Healthcare Engineering
University of North Carolina – Chapel Hill
Disclosures
Communify.us (quality/safety improvement management
…
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psnet.ahrq.gov/node/35236/psn-pdf
June 30, 2011 - Patient perspectives of patient–provider communication
after adverse events.
June 30, 2011
Duclos CW, Eichler M, Taylor L, et al. Patient perspectives of patient-provider communication after adverse
events. Int J Qual Health Care. 2005;17(6):479-86.
https://psnet.ahrq.gov/issue/patient-perspectives-patient-provide…
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psnet.ahrq.gov/node/72770/psn-pdf
February 24, 2021 - Communication about medical errors.
February 24, 2021
Kaldjian LC. Communication about medical errors. Patient Educ Couns. 2021;104(5):989-993.
doi:10.1016/j.pec.2020.11.035.
https://psnet.ahrq.gov/issue/communication-about-medical-errors
Disclosure of and communication about errors and adverse events is increasin…
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psnet.ahrq.gov/node/36832/psn-pdf
August 26, 2011 - The role of information technology in healthcare
communications, efficiency, and patient safety:
application and results.
August 26, 2011
Prince SB, Herrin DM. The role of information technology in healthcare communications, efficiency, and
patient safety: application and results. J Nurs Adm. 2007;37(4):184-7.
ht…
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psnet.ahrq.gov/node/39808/psn-pdf
September 01, 2010 - Handoffs and communication: the underappreciated roles
of situational awareness and inattentional blindness.
September 1, 2010
Gosbee JW. Handoffs and communication: the underappreciated roles of situational awareness and
inattentional blindness. Clin Obstet Gynecol. 2010;53(3):545-58. doi:10.1097/GRF.0b013e3181ec1…
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psnet.ahrq.gov/node/35695/psn-pdf
February 23, 2015 - Communication in critical care environments: mobile
telephones improve patient care.
February 23, 2015
Soto RG, Chu LF, Goldman JM, et al. Communication in critical care environments: mobile telephones
improve patient care. Anesth Analg. 2006;102(2):535-41.
https://psnet.ahrq.gov/issue/communication-critical-care-…
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psnet.ahrq.gov/node/39364/psn-pdf
March 10, 2010 - Improving communication in the ICU using daily goals.
March 10, 2010
Pronovost P, Berenholtz SM, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit
Care. 2003;18(2):71-5.
https://psnet.ahrq.gov/issue/improving-communication-icu-using-daily-goals
This study sought to improve communication…
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psnet.ahrq.gov/node/847048/psn-pdf
April 05, 2023 - Comparison of health care worker satisfaction before vs
after implementation of a communication and optimal
resolution program in acute care hospitals.
April 5, 2023
Friedson AI, Humphreys A, LeCraw F, et al. Comparison of health care worker satisfaction before vs after
implementation of a communication and optima…
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psnet.ahrq.gov/node/74728/psn-pdf
February 02, 2022 - Technology-based closed-loop tracking for improving
communication and follow-up of pathology results.
February 2, 2022
Rajan SS, Baldwin J, Giardina TD, et al. Technology-based closed-loop tracking for improving
communication and follow-up of pathology results. J Patient Saf. 2022;18(1):e262-e266.
doi:10.1097/pts.…
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psnet.ahrq.gov/node/36634/psn-pdf
March 03, 2011 - Surgeon information transfer and communication: factors
affecting quality and efficiency of inpatient care.
March 3, 2011
Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication: factors
affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159-69.
https://psn…
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psnet.ahrq.gov/node/854630/psn-pdf
October 18, 2023 - Physician behaviors associated with increased physician
and nurse communication during bedside
interdisciplinary rounds.
October 18, 2023
Huang KX, Chen CK, Pessegueiro AM, et al. Physician behaviors associated with increased physician and
nurse communication during bedside interdisciplinary rounds. J Hosp Med. 20…
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psnet.ahrq.gov/node/851647/psn-pdf
July 26, 2023 - Statewide perinatal quality improvement, teamwork, and
communication activities in Oklahoma and Texas.
July 26, 2023
Stierman EK, O'Brien BT, Stagg J, et al. Statewide perinatal quality improvement, teamwork, and
communication activities in Oklahoma and Texas. Qual Manag Health Care. 2023;32(3):177-188.
doi:10.109…
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psnet.ahrq.gov/node/38176/psn-pdf
October 29, 2008 - Human error, not communication and systems, underlies
surgical complications.
October 29, 2008
Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical
complications. Surgery. 2008;144(4):557-63; discussion 563-5. doi:10.1016/j.surg.2008.06.011.
https://psnet.ahrq.gov/issue/human-e…
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digital.ahrq.gov/principal-investigator/zhu-xi
January 01, 2024 - Zhu, Xi
Patient care in complex Sociotechnological ecosystems and learning health systems.
Citation
Tu SP, Garcia B, Zhu X, Sewell D, Mishra V, Matin K, Dow A. Patient care in complex Sociotechnological ecosystems and learning health systems. Learn Health Syst. 2024 May 23;8(S…
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psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication
December 30, 2014 - Study
Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.
Citation Text:
Joffe E, Turley JP, Hwang KO, et al. Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a ra…
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psnet.ahrq.gov/issue/disruptive-behavior-operating-room-prospective-observational-study-triggers-and-effects-tense
October 29, 2014 - Study
"Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams.
Citation Text:
Keller S, Tschan F, Semmer NK, et al. “Disruptive behavior” in the operating room: A prospective observational st…
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psnet.ahrq.gov/issue/evaluation-preoperative-checklist-and-team-briefing-among-surgeons-nurses-and
August 28, 2013 - Study
Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication.
Citation Text:
Lingard LA. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Fa…
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psnet.ahrq.gov/issue/unit-based-care-teams-and-frequency-and-quality-physician-nurse-communications
November 16, 2022 - Study
Unit-based care teams and the frequency and quality of physician–nurse communications.
Citation Text:
Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.100…
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psnet.ahrq.gov/issue/improving-self-reported-empathy-and-communication-skills-through-harm-healthcare-response
March 09, 2022 - Study
Improving self-reported empathy and communication skills through harm in healthcare response training.
Citation Text:
Samuels A, Broome ME, McDonald TB, et al. Improving self-reported empathy and communication skills through harm in healthcare response training. J Patient Saf Risk …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix D
CANDOR Tool
PROCESS
QUESTIONS TO REVIEW
Y/N
CONTRIBUTING OR CAUSAL FACTOR Y/N
FINDINGS /
COMMENTS
COMMUNICATION
Did all caregivers have access to all pertinent information needed to make the best decisions for the patient? (e.g.,…