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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/teamstepps-pocket-guide.pdf
May 01, 2023 - .......................11
Effective Team Leadership ..............................12
Effective Team Event … Team Leadership Page 13
Effective Team Event Tools
Sharing the Plan
y Brief—Short session prior to … I-PASS
Team Leadership
Multi-Team System forPatient Care
Effective Team Leadership
Effective Team Event … I-PASS
Team Leadership
Multi-Team System forPatient Care
Effective Team Leadership
Effective Team Event
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www.healthcare411.ahrq.gov/news/blog/ahrqviews/public-health-emergency-refocus.html
May 01, 2023 - England Journal of Medicine that estimated 1 in 4 people hospitalized are at risk of a patient safety event … Trends in adverse event rates in hospitalized patients. JAMA 2022 Jul 12;328(2):173-83.
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www.healthcare411.ahrq.gov/news/newsroom/case-studies/202201.html
January 01, 2022 - Pezzullo described their Safe Table event as a protected forum where participants can feel comfortable … After an IDD Safe Table event held in August 2020 for primary care physicians, attendee feedback forms
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - The use of these five sets of charts also eliminated the need to use 2005-2006
Medicare adverse event … Measures used to estimate the national HAC rate
HAC Type Source Measure
Adverse Drug
Event
MPSMS … Associated With Hip Joint Replacements
MPSMS Adverse Event Associated With Knee Joint Replacements … for all patients for
which the MPSMS data are used, we follow these steps:
• Multiply the adverse event … MPSMS Femoral Artery
Procedures
Puncture for Catheter Angiographic 21,538 0.72
MPSMS Adverse Event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module4/4_ts_office_leading.pptx
January 01, 2006 - 8
Debrief
Short, informal information exchange used as a process improvement tool
Occurs after an event … Leading as event management: toward a new conception of team leadership.
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www.healthcare411.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - Condition Rate
Partnership for Patients Hospital-Acquired Conditions
Source
Measure
Adverse Drug Event … population, rather than as a rate for the subpopulation that has the opportunity to experience the adverse event … for each of the 21 HACs for all patients for which the MPSMS data are used, we multiply the adverse event … (rounded) (updated June 2014)
4,757,000
145
Ideally, we would have estimated the adverse event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-126-section-2-technical-specs.pdf
April 30, 2018 - Event/
diagnosis
Children on any antipsychotic medication for 90 days or more (Table 1).
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www.healthcare411.ahrq.gov/hai/pfp/hacrate2013.html
January 01, 2018 - MPSMS data provide inpatient mortality data for the patients who experienced each type of adverse event … , and for patients who were exposed to risk for the event. 13 These MPSMS mortality data were of interest … For pressure ulcers and falls, 100 percent of patients are exposed to risk for the event; but for other … event types, such as CLABSIs, only a fraction of patients are exposed to risk for the event. … patients who received a central line as part of their inpatient care are considered at risk for the event
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www.healthcare411.ahrq.gov/teamstepps/instructor/fundamentals/module4/igleadership.html
March 01, 2019 - Discussion:
What event necessitated the need for the huddle? … 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 … Held debrief to recap event and share lessons learned. … Use of these tools leads to gaining a shared model or understanding of a situation or event (i.e., shared
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module3/3_ts_office_comm.pptx
December 01, 2005 - January 1995-December 2005
† Joint Commission Sentinel Event Data (Root Causes by Event Type). 2004-2012
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-177-section-2-technical-specs.pdf
May 23, 2014 - Event/ At least two antipsychotic medication dispensing events (Table 1), regardless if they are the … Event/diagnosis At least two antipsychotic medication dispensing events (Table XXX-A), regardless if
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cooperative-context.pdf
June 01, 2013 - (b) What would others need to know about your recruitment experience from a historical or recent event … Stakeholders or Partner Organization Perspective:
Recruitment Experience from a Historical or Recent Event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-241-bmi-communication-section-2-tech-specs.pdf
February 24, 2020 - Event/Diagnosis An outpatient care visit and BMI ≥85% percentile.
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www.healthcare411.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/problem-solving-comp-kit.html
June 01, 2017 - Preparation (examples)
1
Can we draft an "escalation from CUS event" procedure acceptable to organization … Following the first escalation from a CUS event, prepare to debrief: (a) How well did the escalation … CUS contact person determines what communication has occurred with the patient/family regarding the event … CUS contact person leads after-event debrief with organization leaders.
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www.healthcare411.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
December 01, 2017 - at unexpected events, data results, and outcomes to determine all of the underlying causes of the event … Event Analysis
Team notification – Nurse Manager, Medical Director, and Frontline staff notification … – email and huddle
Infection Prevention Council report out
Slide 66
Event Analysis Tool
Image … : Screen shot of a CAUTI Event Analysis form. … Slide 80
Identifying Defects: Defects Can Come From Many Different Sources
Staff feedback
Event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-145-materials-vi-a.pdf
March 01, 2011 - during continuous enrollment period
Anchor Date
Date of ADHD diagnosis at the physician visit
Event … with ADHD (ICD-9-CM 314.0, 314.00, 314.01, any position) who meet aspects of the PMCoE measure
Index event … during continuous enrollment period
Anchor Date
Date of ADHD diagnosis at the physician visit
Event … with ADHD (ICD-9-CM 314.0, 314.00, 314.01, any position) who meet aspects of the PMCoE measure
Index event … with ADHD (ICD-9-CM 314.0, 314.00, 314.01, any position) who meet aspects of the PMCoE measure
Index event
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www.healthcare411.ahrq.gov/teamstepps/officebasedcare/module1/office_intro.html
February 01, 2016 - outcomes include:
50% reduction in the Weighted Adverse Outcome Score, which describes the adverse event … decrease in the Severity Index, which measures the average severity of each deliverty with an adverse event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-240-section-2-technical-specifications.pdf
February 21, 2020 - BMI Body mass index for the child is reported to be ≥85th percentile
Event/Diagnosis Child’s parents
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www.healthcare411.ahrq.gov/evidencenow/heart-health/cholesterol/uspstf.html
September 01, 2018 - cardiovascular disease (CVD) and for those who have one or more CVD risk factors with a calculated 10-year CVD event
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/staff-covid-vaccine-administration-record.docx
May 01, 2022 - Contraindication: __________________________________________________________________________
Adverse Event