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121. TeamSTEPPS Video: STEP for Inpatient Medical Teams | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/resources/additional/step.html
     June 01, 2023 - Even though the patient's vital signs were normal, were there reasons for concern?

122. 109-Performing-Premortem-Project-Assessment-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/109-performing-premortem-project-assessment-fg.docx
     April 01, 2025 - contributed and you feel you have a good group of reasons for failure, rate the reasons by level of concern … from 1 to 5, where 1 is lowest concern. … Choose a few of the reasons you feel have the highest levels of concern and discuss each one, with an

123. Peterson Regional Medical Center Uses AHRQ's CUSP and Hospital Survey to Advance Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201419.html
     November 01, 2014 - Anyone can call a huddle at any point and speak up if they have a concern."    … identified continuing communications issues of the staff being reluctant to speak up when they had a safety concern

124. Systematic Design of Meaningful Presentations of Medical Test Data for Patients - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r01hs021681-zikmund-fisher-final-report-2017.pdf
     January 01, 2017 - The findings suggested that harm anchors were not particularly important to evoking concern about extreme … anchor (“Many doctors are not concerned until here”) was particularly effective an reducing patient concern … Clinicians also expressed concern that the harm anchor design might reassure patients for relatively … based on Study 3 on the effect of providing goal ranges and b) on the use of harm anchors to minimize concern … Providing harm anchors in visual displays of test results mitigates patient concern about nearly normal

125. Changing the narratives for patient safety. | PSNet
     psnet.ahrq.gov/issue/changing-narratives-patient-safety
     April 17, 2019 - August 20, 2018 What counts as a voiceable concern in decisions about speaking out in … 2021 Reframing and addressing horizontal violence as a workplace quality improvement concern

126. Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. | PSNet
     psnet.ahrq.gov/issue/physician-and-nurse-well-being-and-preferred-interventions-address-burnout-hospital-practice
     February 09, 2011 - between clinician burnout and patient safety are not new , the COVID-19 pandemic brought this safety concern … 2, 2021 Nurses' and patients' appraisals show patient safety in hospitals remains a concern

127. Tools for Sustainability: Premortem and Scorecard: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-slides.html
     February 01, 2017 - Slide 18: Premortem Exercise Step 3: Identify the level of concern for each reason. … Image: A line scale displays the level of concern. … The scale runs from lowest to moderate to highest level of concern.

128. Appendix F. | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/measure_retirement/measure_retirementapf.html
     February 01, 2014 - With regard to scientific acceptability, there was some concern that the measure was not risk adjusted … However, no reliability or validity data were available, and members expressed concern that the measure … important for measuring access and monitoring and addressing disparities in care, but there is some concern … to be important for measuring access and monitoring and addressing disparities in care, one common concern … to be important for measuring access and monitoring and addressing disparities in care, one common concern

129. Med List (pdf file)
     digital.ahrq.gov/sites/default/files/docs/resource/Wolf_Q6_Med_List_1_27_09.pdf
     June 16, 2021 - Place a check (√) in the Concerns column next to any concern you may have about the medication. … Place a check (√) in the Concerns column next to any concern you may have about the medication listed

130. Chipra205-Materials Ii (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA205-Materials_II.pdf
     June 02, 2025 - 1 )" Union of: "Communication: From Patient to Provider: indication from the family that there was concern … 1 )" Union of: "Communication: From Patient to Provider: indication from the family that there was concern … 1 )" Union of: "Communication: From Patient to Provider: indication from the family that there was concern … Data Elements) "Communication: From Patient to Provider: indication from the family that there was concern … about child's development" using "indication from the family that there was concern about child's development

131. Supplemental nurse staffing in hospitals and quality of care. | PSNet
     psnet.ahrq.gov/issue/supplemental-nurse-staffing-hospitals-and-quality-care
     February 09, 2011 - As temporary nurses may be less familiar with hospital procedures, the concern has been raised that excessive … 16, 2012 Nurses' and patients' appraisals show patient safety in hospitals remains a concern

132. Medication Dashboard Data 2025 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2025.xlsx
     January 01, 2025 - Dashboard Name Worksheet Name Description of Medication/Substance Event by Type of Safety Concern … dashboard/medication.html Med_1 Med_1: Description of Medication/Substance Event by Type of Safety Concern … Description of Medication/Substance Event Safety Concern Frequency Percent Incorrect action (process … Med_2 Med_2: Stage of Origin for Safety Concerns Safety Concern Stage Event Originated Frequency Percent … Med_3 Med_3: Type of Medication/Substance Involved by Safety Concern Safety Concern Type of Medication

133. Tool: STEP | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/situation/tools/step.html
     June 01, 2023 - Progress: The respiratory therapist notifies the oncoming nurse of their concern.  … Even though the patient’s vital signs were normal, were there reasons for concern?

134. An Automatic Notification System for Test Results Finalized After Discharge - 2012 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/automatic-notification-system-test-results-finalized-after-discharge/annual-summary/2012
     January 01, 2012 - One important patient safety concern is failure of responsible providers to followup on test results … notification is a promising strategy to manage TPADs, potentially mitigating an unresolved patient safety concern

135. Discussion | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-discuss.html
     November 01, 2017 - Conversely, the few studies that estimate “any HAC”-related cost and mortality circumvent the competing risk concern … While these types of studies garner headlines because of the magnitude of the overall concern, the tradeoff … Another concern is that, although the QSRS Common Formats for Surveillance definitions use clinical information … A final data concern is that many of the studies included in the meta-analysis did not directly report

136. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/154-performing-pre-mortem-project-assessment.pptx
     October 01, 2024 - Rate the reasons by level of concern from 1 to 5, where 1 is lowest. … Choose reasons with high levels of concern to discuss and develop action plans.

137. Mini Presentation: Performing a Premortem Project Assessment
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/108-performing-premortem-project-assessment.pptx
     April 01, 2025 - Rate the reasons by level of concern from 1 to 5, where 1 is lowest. … Choose reasons with high levels of concern to discuss and develop action plans.

138. Prescribing Safety in Ambulatory Care: Physician Perspectives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rundall.pdf
     January 01, 2003 - Another respondent expressed his concern about the result of the inherent inability of physicians to … Some physicians expressed concern that they were often put in the position of prescribing drugs for … The third most commonly cited concern was safety of prescribing drugs for the elderly (11 mentions). … Another concern frequently mentioned was the safety of chronic medication use (nine mentions). … While harm from medication errors represents a significant national concern, many individual health

139. TeamSTEPPS for Diagnosis Improvement: Knowledge Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-knowledge-assessment.pdf
     February 01, 2022 - Voice his or her concern a second time, more forcefully, to ensure the correction is heard. c. … Use of the Two Challenge Rule to ensure that your concern has been heard. c. … Voice his or her concern a second time, more forcefully, to ensure the correction is heard.

140. Good Catch in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/good-catch-operating-room
     August 27, 2017 - Although the surgeon was surprised by the anesthesiologist's forcefulness, he recognized her concern, … The Two-Challenge Rule is a communication strategy designed to ensure that a concern is properly emphasized … Its framework requires the individual harboring the safety concern to voice it to the appropriate person … The concern should be stated in an assertive manner, and the team member being challenged must acknowledge … Second, she stated her concern that she could not determine the cause of the patient's hypotension.