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healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
October 01, 2023 - Skip to main content
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/implguide_0.pdf
March 01, 2006 - variety of sources, including
adverse event and near-miss reports, reports of root cause analyses or failure … Reviewing reports of root cause analyses and failure modes and effects analyses. … process as you imagine it would look with your TeamSTEPPS
Intervention in place.
Identify potential failure … Failure to show improvement in team performance or in clinical outcomes may be due
to the staff’s failure … Mark potential failure points in the redesigned processes.
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healthcare411.ahrq.gov/talkingquality/translate/organize/index.html
March 01, 2016 - , effectiveness, timeliness)
Organizing Measures by Disease or Condition (e.g., congestive heart failure
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healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
December 01, 2022 - Skip to main content
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Careers
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healthcare411.ahrq.gov/cahps/cahps-database/hcbs-database/participate.html
January 01, 2024 - Failure to follow these guidelines will result in your data not being included in the database.
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healthcare411.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - It is important to reinforce what went well and avoid assigning blame or failure to any individual regarding
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healthcare411.ahrq.gov/cahps/cahps-database/hp-database/participate.html
December 01, 2023 - Failure to follow these guidelines will result in your data not being included in the database.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule5.pptx
February 06, 2006 - Usually the loss of situation awareness is as a result of the team members failure to share information … Some of the specific examples for where failure can occur in the STEP process-- remember the STEP mnemonic … -- status of the patient, there would be a failure to take a patient's vital signs; in the team considerations … , a failure to assist a team member who you know is overloaded; environmentally, failure to know where … the necessary equipment is stored; and the progress towards the goal, a potential failure to call a
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-probabilistic-thinking.pdf
September 01, 2022 - example, an 80-year-old man with hypertension and lower extremity edema who is worried about heart
failure … The clinician might explain
the low likelihood of heart failure, the impact of results of a BNP test … not performing
the test by stating, “Someone like you has about a 2 percent chance of having heart failure … If we do a BNP
test and it’s abnormal, that chance of heart failure would rise to about 8 percent.”
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/leadership-communication.pdf
January 01, 2018 - If leaders aren’t
proactively listening, chances are they are setting themselves up for failure.
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healthcare411.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html
January 01, 2020 - evidence for implementation when people are engaged in making something work rather than focused on the "failure … Psychological barriers such as fear of change, fear of failure, grief over loss of familiar processes … for two of the fundamental barriers to change: the fear of new ways of doing things and the fear of failure
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healthcare411.ahrq.gov/teamstepps/longtermcare/downloads.html
April 01, 2013 - file, 14.2 MB)
Sue Sheridan video on Patient Safety (Zip file, 216 MB)
Team Structure
All Team Failure
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
November 01, 2012 - Postoperative respiratory failure is not currently part of Medicare’s Hospital Value-Based
Purchasing … Also consider performing a failure mode and effects analysis to better understand
the process and where
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps-webinar-030817.ppt
January 01, 2017 - Organization (2008)
Sensitivity to Operations (Situational Awareness)
Reluctance to Simplify (Multiple Failure … RCA/ACA)
(Healthy) Preoccupation with Failure
(Situationally Appropriate) Deference to Expertise
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healthcare411.ahrq.gov/talkingquality/measures/setting/physician/examples.html
September 01, 2019 - Education and counseling for patients with certain conditions (e.g., hepatitis, heart failure).
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healthcare411.ahrq.gov/talkingquality/plan/quality-measures.html
November 01, 2018 - example, CalHospitalCompare’s Web site has information about heart attack, heart bypass surgery, heart failure
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2023.pdf
March 01, 2024 - related to financial payouts; up to one-
third of all cases that end in a claim have a diagnostic failure
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1c_combo_pdifactsheet.pdf
October 01, 2015 - 0340 2012
PDI 08 Perioperative Hemorrhage or Hematoma Rate 5.2
PDI 09 Postoperative Respiratory Failure
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/coaching/lepslcoaching.pdf
July 26, 2012 - Understanding
Performance Improvement
Setting Performance Goals
Rewarding Improvement
Dealing With Failure
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/coachslhandouts.pdf
July 25, 2012 - Understanding
Performance Improvement
Setting Performance Goals
Rewarding Improvement
Dealing With Failure