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1121. PowerPoint Presentation
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-implementation-slides.pptx
      February 28, 2022 - PowerPoint Presentation Implementing TeamSTEPPS Introduction Reflecting on Day 1 Day 2 Preview Patient safety is threatened by poor communication and teamwork. TeamSTEPPS provides tools and a framework to improve both. Questions or reflections on day 1. 2 2 Preparing for Day 2 Day 2 Preview Day 1: Int…

1122. Job Aid: Introduction to Quality Improvement (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-intro-qi.pdf
      May 18, 2021 - Job Aid: Introduction to Quality Improvement Primary Care Practice Facilitator Training Series 1 Job Aid: Introduction to Quality Improvement Quality Improvement (QI) Basics The QI Process You will be helping practices to:  Identify areas for improvement.  Set goals.  Develop a plan that…

1123. HIT Resource List (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/healthitresourcelist.pdf
      January 01, 2019 - new way of recording and communicating medical information has also introduced new opportunities for error

1124. Scoring CPCQ (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cpcq-scoring.pdf
      May 01, 2017 - a low number of imputations the results may even be somewhat more variable because of simulation error

1125. Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2020 User Database Report Part I (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2020_MOSOPS_Part_I-rev0921.pdf
      January 01, 2020 - Communication About Error Organizational Learning Patient Care Tracking/ Followup Work Pressure … SOPS Medical Office Survey Composite Measures Definition: The extent to which… Communication About Error … Communication About Error Staff feel like their mistakes are held against them. … Communication About Error 74% 15.51% 25% 53% 63% 75% 86% 93% 100% 7. … Communication About Error 1. Staff feel like their mistakes are held against them.

1126. TeamSTEPPS 2.0 Module 6: Mutual Support
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule6.pptx
      February 09, 2006 - expected that assistance will be actively sought and offered as a method for reducing the occurrence of error … And this makes us more apt to make an error.

1127. Event Investigation and Analysis Guide: Appendix A | Agency for Healthcare Research and Quality
      www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.html
      August 01, 2022 - If someone misreads a label or makes a typing error, we do not have accurate information in our database

1128. Measure: Initial Risk Assessment for Immobility-Related Pressure Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra-16-p002-1-ef.pdf
      May 01, 2016 - Measure: Initial Risk Assessment for Immobility-Related Pressure Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission Measure: Initial Risk Assessment for Immobility-Related Pressure Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission Measure Developer: Pediatric Measurem…

1129. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Patient and Family Engagement
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/engagement.pptx
      May 01, 2017 - Medical error: the second victim. The doctor who makes the mistake needs help, too.

1130. Learn-From-Defects-Facilitator-Guide (doc file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
      May 01, 2017 - Active failures are also called human error. … These conditions are the mistakes that occur without human error.

1131. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4i_pdi11-dehiscence-bestpractices.pdf
      May 17, 2016 - factors can be addressed by hospitals, such as improving nutritional status and decreasing surgical error

1132. Surveys on Patient Safety Culture (SOPS®) Medical Office Survey: 2022 User Database Report Part I (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2022-mosops-database-report-part-I.pdf
      January 01, 2022 - SOPS Medical Office Survey Composite Measures Definition: The extent to which… Communication About Error … Organizational Learning Overall Perceptions of Patient Safety and Quality Communication About Error … Communication About Error Providers and staff talk openly about office problems. … Communication About Error 72% 16.65% 17% 49% 59% 74% 84% 93% 100% 6. … From 2012 to 2022, Communication About Error showed the highest increase in average percent positive

1133. Warm Handoffs: A Guide for Clinicians (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-guide-for-clinicians.pdf
      February 10, 2017 - Warm Handoffs: A Guide for Clinicians Why is it important? Communication breakdowns can result in medical errors. Warm handoffs can help address communication issues and: ■ Engage patients and families and encourage them to ask questions. ■ Allow patients to clarify or correct the information exchanged. ■…

1134. Central Venous Catheter Insertion Bundle Facilitator Notes (doc file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/central-catheter-insertion-notes.docx
      April 01, 2022 - But streamlining products can save time and money and prevent opportunities for error if staff are unfamiliar

1135. PowerPoint Presentation
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/prescribers-slides.pptx
      June 01, 2021 - failures were the root cause of the majority of sentinel events Intimidation can lead to medication error

1136. Patient and Family Engagement in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
      www.qualitymeasures.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-fac-notes.html
      May 01, 2017 - When an error does occur, patients and families tend to blame the provider and not the system.

1137. OBC PPT Q4
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2018-materials/ts-obc-webinar-uw.pptx
      January 01, 2018 - More than 1 billion ambulatory visits 12 million ambulatory care patients experience a diagnostic error

1138. Process
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/pharmlitqi/slidedeck1/slidedeck1.pptx
      March 01, 2011 - Process Health Literacy in Pharmacy: Introduction Curricular Modules for Pharmacy Faculty Content adapted from Kripalani and Jacobson (2007) 0 Objectives Introduction to health literacy Health literacy skills Health system demands Consequences of a mismatch Implications for pharmacy 1 The presentatio…

1139. Implementation Guide for Automatic Referral: Building, Implementing, and Troubleshooting and Automatic Referral for Cardiac Rehabilitation (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/implementing-automatic-referral-implementation-guide.pdf
      March 01, 2023 - A common error is to relinquish the design and implementation of AR to the IT department.

1140. HERO: New Mexico's Health Extension as a Model for Primary Care Transformation (pdf file)
      www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/impact-profile-nm.pdf
      April 01, 2015 - Through trial and error, the New Mexico IMPaCT team learned that practices were more open to participating