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  1. preventiveservices.ahrq.gov/workingforquality/events/webinar-introduction-to-the-stakeholder-toolkit.html
    November 01, 2016 - Agenda [Slide 2] Ann Gordon: My name is Ann Gordon and I will be facilitating today's event. … But do know that a copy of the slides from this presentation as well as a transcript of today's event … Wilson before wrapping up today's event? Dr. … Look for an email from us in the coming days directing you to the archive of today's event.
  2. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support.pptx
    July 01, 2023 - Although this video doesn’t showcase feedback within the context of an obstetric hemorrhage event, think … Use DESC to provide feedback during debriefs or in one-on-one interactions between providers post-event … Sonentag was called twice by the charge nurse before coming in person to attend to the hemorrhage event … Sonentag feedback about this event. 32 Obstetric Hemorrhage DESCR Script The L&D director approaches … Sonentag to offer feedback on the most recent hemorrhage event. 33 Dr.
  3. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support-speaker-notes.pdf
    July 01, 2023 - Although this video doesn’t showcase feedback within the context of an obstetric hemorrhage event, think … If not possible to • Post‐case or event to address it in the moment, wait manage fallout from until … Use DESC to provide feedback during debriefs or in one‐on‐one interactions between providers post‐event … Sonentag was called twice by the charge nurse before coming in person to attend to the hemorrhage event … Sonentag to offer feedback on the most recent hemorrhage event. 29 Dr.
  4. preventiveservices.ahrq.gov/news/newsroom/press-releases/nac-meeting-nov17.html
    November 01, 2022 - Closed captioning will be provided during this event.
  5. preventiveservices.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety-fac-guide.html
    July 01, 2023 - facilitating a safe delivery by offering logic and a clear focus during what can often be a chaotic event … risk of hemorrhage, or patient preferences that may limit the use of blood and blood products in the event … Fostering a culture that supports debriefing by the clinical team immediately after a near miss, an adverse event … A unit can decide its approach to debriefing events based on the seriousness of the event, expertise
  6. preventiveservices.ahrq.gov/cahps/about-cahps/principles/index.html
    January 01, 2020 - CAHPS reporting questions provide an explicit time frame (e.g., in the past six months) or event reference
  7. preventiveservices.ahrq.gov/news/newsroom/press-releases/ahrq-nac.html
    March 01, 2024 - Closed captioning will be provided during this event.
  8. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsinstructmod.ppt
    January 01, 2008 - to the response team and who follow a patient from one care unit to the next during a rapid response event … Data collection at this university includes: Conducting event debriefing. … SAY: Responders conduct typical debriefs right after the event to give teams an opportunity to conduct … Sensemaking reviews are typically conducted after an event, much like a debrief. … This is typically indicative of an attempt to uncover what might have gone wrong during an uncommon event
  9. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
    March 08, 2019 - • Partnership with VA to look at data, trends, and solution for delay in treatment event type.
  10. preventiveservices.ahrq.gov/teamstepps/rrs/instructor_slides/rrsinstructmod.html
    October 01, 2014 - to the response team and who follow a patient from one care unit to the next during a rapid response event … Data collection at this university includes: Conducting event debriefing. … Say: Responders conduct typical debriefs right after the event to give teams an opportunity to conduct … Sensemaking reviews are typically conducted after an event, much like a debrief. … This is typically indicative of an attempt to uncover what might have gone wrong during an uncommon event
  11. preventiveservices.ahrq.gov/patient-safety/news-events/index.html
    March 01, 2024 - 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 …
  12. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-tpq-questionnaire.pdf
    May 31, 2023 - My supervisor/manager provides opportunities to discuss the unit’s performance after an event.
  13. preventiveservices.ahrq.gov/talkingquality/translate/compare/choose/standard.html
    January 01, 2023 - While “zero-tolerance” is implied by the term “never event,” this may not be language that the public
  14. preventiveservices.ahrq.gov/news/newsletters/e-newsletter/899.html
    February 01, 2024 - Speakers at the event, sponsored by AHRQ and the National Institutes of Health, highlighted major drivers
  15. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/safe_surgery_finalreport.pdf
    December 01, 2017 - SSIs are the third most costly healthcare-associated infection (HAI) per event, accounting for more … SSIs are the third most costly healthcare-associated infection (HAI) per event, accounting for more … We also found statistically significant improvements in frequency of event reporting (+6.3%, p < .003 … Since scores for frequency of event reporting and teamwork across settings are each composited from … All 3 items that compose the dimension frequency of event reporting improved significantly.
  16. preventiveservices.ahrq.gov/teamstepps/readiness/index.html
    August 01, 2015 - Objective information can originate from a variety of sources, including adverse event and near-miss … For continued success, the organization needs to view the culture change as a process rather than an event
  17. preventiveservices.ahrq.gov/teamstepps/instructor/essentials/igessentials.html
    March 01, 2019 - A call-out is a tactic used to communicate critical information during an emergent event. … It also benefits a recorder when present during a code or emergent event. … Analysis of why the event occurred, what worked, and what did not work. … Debriefs can be a brief (about 3 minutes or less) team event, typically initiated and facilitated by … Is there something—such as a life event or situation at work—that is detracting from my ability to focus
  18. preventiveservices.ahrq.gov/news/newsroom/press-releases/national-advisory-meeting-july-14.html
    July 01, 2021 - Closed captioning will be provided during this event.
  19. preventiveservices.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-teamwork-leadership.pdf
    March 01, 2024 - 2023. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety- topics/sentinel-event … /03162023_sentinel-event-_annual-review_final-(002).pdf. … SAFETY https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event … https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event … Although a final report was not available, a review (Robson, 2001) of the event noted that participants
  20. preventiveservices.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-fac-guide.html
    July 01, 2023 - responding and expectations for the response, uniform expectations for documentation of the rapid response event … An event that requires a team response. … The L&D unit can decide its approach to learning from defects based on seriousness of event, expertise

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