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www.qualitymeasures.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - Analysis of why the event occurred, what worked, and what did not work. … Debriefs can be a short (about 3 minutes or less) team event, typically initiated and facilitated by
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-150-section-2-tech-specs.pdf
November 01, 2014 - Event/
diagnosis
At least two antipsychotic medication dispensing events (Table 1), regardless if … Event/diagnosis At least two antipsychotic medication dispensing events (Table XXX-A), regardless if
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7c.pdf
February 02, 2018 - 0.10 <0.001
No Insurance 102 (3.2%) 0.04 0.001
Table VII.C.2 – Analysis of differences in adverse event
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-section-6-table-5.pdf
April 26, 2018 - Inter-Rater Reliability of Assessment of Event within Specified Time Period
Site Time Total
Records
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7a.pdf
February 02, 2018 - 12.4%) 0.18 <0.001
Other 161 (5.7%) 0.12 0.12
Table VII.A.2 – Analysis of differences in adverse event
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www.qualitymeasures.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/strategies-slides.html
March 01, 2017 - 2
According to Sentinel Event data compiled by the Joint Commission between 1995 and 2005, ineffective … Root Causes by Event Type, 2004-2Q 2014. Sentinel Event Data. … Root Causes by Event Type, 2004-2Q 2014. Sentinel Event Data.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/impworkbook.pdf
December 11, 2015 - □ Adverse event due to a breakdown in team skills (e.g., communications, situation monitoring,
mutual … es) due to breakdowns in team skills
□ Staff members are concerned that we could have an adverse event … process failures)
Incorporates redundancy and backup systems to minimize risk of patient harm in event … Examples
include event counts, rates (percentages), survey scores, and time-to-event occurrences.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/qi-action-slides.pptx
April 01, 2022 - QI in Action ׀ 25
25
Resources6-9
ICU Action Plan Template
CUSP Learn From Defects Tool
CAUTI Event … Report Tool
CLABSI Event Report Tool
Institute for Healthcare Improvement’s Plan-Do-Study-Act (PDSA) … CAUTI Event Report Template. http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools … Central Venous Catheter-Associated Laboratory-Confirmed Blood Stream Infection Event Report Template
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7b.pdf
February 02, 2018 - 3 or more body systems 125 (3.6%) 0.27 <0.001
Table VII.B.2 – Analysis of differences in adverse event
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module1/1_ts_office_intro.pptx
January 01, 2010 - 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 delivery with an adverse event
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/dental.pdf
March 19, 2014 - Instructor Comments
A call-out is a tactic used to communicate critical information or an emerging event … This communication failure results in an adverse event. … In the
event of high workload, team members are expected to prioritize and assist teammates to
ensure
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www.qualitymeasures.ahrq.gov/evidencenow/projects/heart-health/evidence/cholesterol.html
March 01, 2021 - CVD) in adults aged 40 to 75 years, with at least one CVD risk factor and an increased risk of a CVD event … The USPSTF recommended discussing statin use in similar patients with more moderate risk of a CVD event … 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.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-216-section-2-tech-specs.pdf
February 26, 2018 - Ages Younger than eighteen years of age during measurement year
Event/Diagnosis Diagnosed with sickle … Administration of oral
antibiotics does not qualify as a numerator event.
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www.qualitymeasures.ahrq.gov/npsd/data/dashboard/generic.html
September 01, 2023 - This dashboard includes information for event and report types organized by year (annual trends), examines
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-148-section-2-tech-specs.pdf
February 22, 2019 - • Clarified that schizoaffective disorder is included in step 4 of the event. … Event Follow the steps below to identify the eligible population.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module3/slcommunication.pptx
December 01, 2005 - Causes and Percentages for Sentinel Events (All Categories) January 1995−December 2005)
** (JC Sentinel Event … Data (Root Causes by Event Type) 2004-2012)
TEAMSTEPPS 05.2
Mod 3 2.0 Page ‹#›
Communication
-
www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/app-a.html
September 01, 2020 - particularly frontline staff and interpreters, on the full spectrum of what constitutes a patient safety event … training and educational sessions in this area:
Include a focus on the definition of a patient safety event … Our study revealed that nonclinical staff might not report a patient safety event since they believe
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/management/problem-solving/problem-solving-component-kit.docx
May 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.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/leadership-communication.pdf
January 01, 2018 - Belfer shared this anecdote during a recent Advisory Roundtable event convened by
athenahealth. … “You cannot over-communicate for primary care physicians,” Belfer said at the
event.
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www.qualitymeasures.ahrq.gov/teamstepps-program/curriculum/communication/tools/callout.html
May 01, 2023 - Afterwards, consider how the use of call-outs helped the team during an emergent event:
How did the … call-outs made by the nurse and intern aid the team during this emergent labor and delivery event?