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www.ahrq.gov/sites/default/files/wysiwyg/topics/bridging-feedback-gap.pdf
June 21, 2021 - Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes
VIEWPOINT
Bridging the feedback gap: a
sociotech…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
January 01, 2003 - An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors
39
An Analysis of Nurses’ Cognitive Work:
A New Perspective for Understanding
Medical Errors
Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson,
Jennifer Sledge, Clay Dunagan, Bradley Evanoff
Abstract
He…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
March 01, 2004 - Identifying Barriers to the Success of a Reporting System
167
Identifying Barriers to the Success
of a Reporting System
Michelle L. Harper, Robert L. Helmreich
Abstract
Spurred by a controversial report from the Institute of Medicine on the prevalence
of medical error, To Err Is Human, the medical profe…
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/womenhealth/2014nhqdr-womenhealth.pptx
January 01, 2020 - report to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129)
Provides a comprehensive … cervical cancer screening is through federally supported community health centers (CHCs), which provide comprehensive
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp3.pdf
March 01, 2009 - The reports and assessments provide organizations with comprehensive, science-
based information on common … For example, a comprehensive and
transparent search strategy, with adequate justifications for inclusion
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Galt.pdf
April 23, 2004 - medication safety research in the primary care office setting.8
Objective
This research describes a comprehensive … These results suggest that
pharmacists should continue comprehensive patient counseling at the time
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/venous-thromboembolism-1.pdf
March 01, 2020 - available
anticoagulants.6 Finally, a meta-analysis performed by Wang et al. (2017) sought to provide a
comprehensive … of both PE and DVT, was nearly significantly lower for
those on aspirin (p=0.052).10
In a more comprehensive
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - The
QDR provides a comprehensive overview of the quality of healthcare received by the general
U.S. … safety culture
• Methods: Implementing evidence-based, practical resources and concepts from the
Comprehensive … safety culture
• Method: Implementing evidence-based, practical resources and concepts from the
Comprehensive
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www.ahrq.gov/hai/cusp/videos/02d-psych-safety/index.html
June 01, 2018 - Psychological Safety
CUSP Toolkit
The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit.
Psychological Safety …
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www.ahrq.gov/hai/cusp/toolkit/infection-checklist.html
December 01, 2012 - Infection Checklist
CUSP Toolkit
Who should use this tool? Infection preventionists.
Checklist items
Leader Responsible
Date Started
1. Meet with the CEO and hospital project leader to learn about the initiative and understand the infection prevention (IP) roles.
2. Introduce …
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www.ahrq.gov/hai/cusp/toolkit/board-checklist.html
December 01, 2012 - Board Checklist
CUSP Toolkit
Who should use this tool? Senior leaders.
Checklist items
Leader Responsible
Date Initiated
1. Set an organization aim of annually assessing the safety and teamwork climate.
2. Improve the safety and teamwork climate using valid measures.
…
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www.ahrq.gov/hai/cusp/toolkit/observing-rounds.html
December 01, 2012 - Observing Patient Care Rounds
CUSP Toolkit
Communication among disciplines can be improved if viewed through the eyes of an objective observer.
Problem statement: Interdisciplinary rounds are in the best interest of patients. Poor communication among staff is a root cause of many patient adverse and sentin…
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www.ahrq.gov/hai/cusp/toolkit/shadowing.html
December 01, 2012 - Shadowing Another Professional Tool
CUSP Toolkit
Learn about other disciplines to improve the coordination of patient care.
Problem Statement: Health care delivery is a multidisciplinary practice that requires coordination of care among different professions and provider types. However, health care provide…
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www.ahrq.gov/hai/cusp/toolkit/morning-briefing.html
December 01, 2012 - Conducting a Morning Briefing
CUSP Toolkit
Improve communication with nursing staff
Problem statement: Physicians can improve communication with nursing staff while more efficiently prioritizing patient care delivery and admissions and discharges.
What is a Morning Briefing? A morning briefing is a dial…
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www.ahrq.gov/hai/cusp/modules/implement/teamwork.html
December 01, 2012 - Implement Teamwork and Communication
CUSP Toolkit
The Implement Teamwork and Communication module of the CUSP Toolkit will help you to identify barriers to communication.
Contents
Slide 1. Cover Slide
Slide 2. Learning Objectives
Slide 3. Basic Components and Process of Communication 2
Slide 4. Four…
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www.ahrq.gov/hai/cusp/modules/apply/sl-cusp.html
December 01, 2012 - Presentation Slides
CUSP Toolkit, Apply CUSP
The Apply CUSP module of the CUSP Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes towards risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit, including TeamSTEPP…
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www.ahrq.gov/hai/cusp/videos/02b-the-4e/index.html
June 01, 2018 - The 4 E's
CUSP Toolkit
The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit.
The 4 E's — Engage, Educate, Exec…
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www.ahrq.gov/hai/cusp/videos/01a-intro/index.html
June 01, 2018 - Introduction
The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit.
Learn About CUSP [10 min. 10 sec.]
YouTube…
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www.ahrq.gov/hai/cusp/videos/03a-engage-senior-exec/index.html
June 01, 2018 - Engage the Senior Executive
CUSP Toolkit
The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit.
Engage the Seni…
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www.ahrq.gov/hai/cusp/toolkit/bckgrnd-qi-team.html
December 01, 2012 - Background Quality Improvement Team Information Form
CUSP Toolkit
Health care provider roles
Who should use this tool? Health care providers.
Please indicate people designated as Quality Improvement Team Members. Your team may not have people who serve in all of these roles.
These in…