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141. SITUATION MONITORING
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module1/1_ts_office_intro-ig.pptx
     January 20, 2006 - TeamSTEPPS has evolved from research in these high-risk fields, where the consequences of error are great … provides specific tools and strategies for improving communication and teamwork, reducing chance of error

142. AHRQ's Quality & Patient Safety Programs by Setting: Ambulatory Care | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/patient-safety/settings/ambulatory/index.html
     July 01, 2022 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

143. COMMUNICATION
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module3/3_ts_office_comm-ig.pptx
     January 01, 2008 - these data illustrate, failure to communicate effectively as a team significantly increases the risk of error … communication—Nonverbal communication requires verbal clarification to avoid making assumptions that can lead to error … about who is responsible for care and for decision-making has often been a major contributor to medical error

144. Advances in Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/patient-safety/reports/liability/index.html
     August 01, 2017 - and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Error … Pronovost Error Disclosure Training and Organizational Culture Jason M. Etchegaray, Thomas H.

145. New Challenge Competition Offers Prizes for Ideas on Advancing AHRQ’s CDS Connect | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/news/newsletters/e-newsletter/881.html
     September 01, 2023 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

146. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-slides.html
     July 01, 2023 - Slide 15: Understanding Risk and Human Behavior 3 Image: Human Error refers to inadvertently doing … Slide 16: Managing Error and Risk 3 Image: Three text boxes contain the following: Human Error

147. PS Grantee Report | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/research/findings/final-reports/index.html?page=7
     December 01, 2007 - 7 8 9 next › ›› last » Last » Medication Error … Human Factors Approaches To Improve Patient Safety Publication Date: December 2006 Medication Error

148. Module 6 Evidence Base (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module6/ts2-0ltc_module6_support_evbase.pdf
     January 01, 2013 - team member who cannot perform a task (e.g., inexperienced, incapable, overburdened, about to make an error … Error reduction and performance improvement in the emergency department through formal teamwork training

149. Toolkit to Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/hai/tools/ambulatory-care/safe-transitions.html
     December 01, 2017 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

150. Change Management (Instructor Guide) (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module8/ts2-0ltc_module8_ig_chmgmt.pdf
     June 09, 2017 - Change Management (Instructor Guide) CHANGE MANAGEMENT: HOW TO ACHIEVE A CULTURE OF SAFETY SUBSECTIONS • Eight Steps of Change • Errors Common in Organizational Change • Culture Change Comes Last, Not First • Change Strate…

151. AHRQ's 35th Anniversary | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/cpi/about/35th-anniversary/index.html
     April 01, 2024 - Quality & Safety , was the largest of its kind at the time to address the frequency of diagnostic error … It concluded that an estimated 12 million U.S. adults will experience an outpatient diagnostic error … AHRQ continues to invest in research to produce tools and resources that help reduce diagnostic error

152. TeamSTEPPS Fundamentals Course: Module 3. Communication | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
     March 01, 2019 - these data illustrate, failure to communicate effectively as a team significantly increases the risk of error … you describe an example in which a communication breakdown was the major contributing factor of an error … To avoid making assumptions that can lead to error, you should verify in writing or orally any nonverbal … about who is responsible for care and decisionmaking has often been a major contributor to medical error

153. TeamSTEPPS for Office-Based Care: Change Management | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/teamstepps/officebasedcare/module9/office_mgmt-ig.html
     September 01, 2015 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

154. AHRQ Safety Program for Perinatal Care: Shadowing Another Professional Tool (doc file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/professional-tool.docx
     May 01, 2017 - Did you observe any error in the interpretation or delivery of an order? 5.

155. Strategy 2: Communicating to Improve Quality (Tool 3) (doc file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-c.docx
     April 13, 2017 - Sometimes fixed teams can become complacent, which creates opportunities for error.

156. Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
     March 01, 2016 - Missed nursing care is a subset of the category known as error of omission. … Thus, missed nursing care not only constitutes a form of medical error that may affect safety, but also … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … This Institute for Healthcare Improvement Web page outlines change concepts such as error proofing, … seeking help in the aftermath of a serious organizational event, most often a significant medical error

157. Patient Safety Tools | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
     June 01, 2022 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

158. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part I: Main Report (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt1-transition-updated.pdf
     June 01, 2022 - Shifting to a “Just Culture” framework to assess Response to Error; 4. … Survey Items Communication Openness Communication Openness 3 4 Feedback and Communication About Error … Communication About Error 3 3 Frequency of Events Reported Reporting Patient Safety Events 3 2 Handoffs … Support for Patient Safety Hospital Management Support for Patient Safety 3 3 Nonpunitive Response to Error … Response to Error 3 4 Organizational Learning – Continuous Improvement Organizational Learning—

159. Primary Care Practice Facilitation Curriculum Module 8: Approaches to Quality Improvement (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-8-approaches-to-qi.pdf
     September 01, 2015 - apple” theory), to QI, where we ask, “How did the system fail to support the worker involved in an error … approach to improvement shifted focus from individuals to underlying processes as the primary source of error

160. Resource List - AHRQ Ambulatory Surgery Center Survey (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
     April 01, 2023 - Missed nursing care is a subset of the category known as error of omission. … Thus, missed nursing care not only constitutes a form of medical error that may affect safety, but has … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … Staff can use this decision tree when analyzing an error or adverse event in an organization to help … organizations seeking help in the aftermath of a serious organizational event, most often a significant medical error