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pbrn.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - Hematoma
PSI 10: Postoperative Physiologic and Metabolic Derangement
PSI 11: Postoperative Respiratory Failure … Surgery Mortality *
PDI 08: Perioperative Hemorrhage or Hematoma
PDI 09: Postoperative Respiratory Failure
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pbrn.ahrq.gov/teamstepps-program/welcome-guides/new-trainers.html
July 01, 2023 - SHARE:
More topics in this section
TeamSTEPPS Program
TeamSTEPPS Updates
Welcome Guides
Patients & Family Caregivers
Frontline Providers
Administrators
Experienced Trainers
New TeamSTEPPS Trainers
Trainers of Preprofes…
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pbrn.ahrq.gov/patient-safety/reports/advancing/index.html
July 01, 2022 - Participants received training on tools and topics including analyzing root causes, analyzing health care failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsinstructmod.ppt
January 01, 2008 - RRSs are established to “respond to a ‘spark’ before it becomes a ‘forest fire,’” thereby preventing failure … Failure Modes and Effects Analysis (FMEA)
This answers questions like:
What can go wrong? … Systems
Rapid Response Systems
SCENARIO 2
The RRT was called for a patient who had a risk of respiratory failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/instructor_slides/rrsinstructmod.pdf
January 01, 2008 - established to “respond to a ‘spark’
before it becomes a ‘forest
fire,’”
thereby preventing failure … Failure Modes and Effects Analysis (FMEA)
This answers questions like:
•What can go wrong? … Rapid Response
Systems SCENARIO 2
The RRT was called for a patient who had a risk of respiratory
failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module4/ebleadership.pdf
January 01, 2013 - TeamSTEPPS 2.0 Evidence Base: Leading Teams
TeamSTEPPS 2.0 Evidence Base: Leading Teams – B-4-27
Leading Teams
Evidence Base: Leading Teams
Leadership has been identified by team researchers as an important component for effective
teamwork 1 by facilitating and progressing team development and performance.2…
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pbrn.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-slides.html
July 01, 2023 - Fear of conflict, intimidation, and failure to function as a team.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring.pptx
May 01, 2017 - interpretation of EFM;
Poor communication related to EFM findings; and
Fear of conflict, intimidation, and failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar05/mixed_methods.pptx
December 03, 2013 - Led by Provider A Team 5 Led by Provider B
Coronary artery disease 77% 91%
Diabetes 65% 78%
Heart Failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
July 02, 2008 - Usually when a deep pressure injury develops, it reflects a system failure.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_PFE_Benefits_Hosp_508.docx
January 01, 2012 - national averages on several core quality measures, including care for heart attack, pneumonia, heart failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-july2015.pptx
January 01, 2015 - Partnership
19
Lawsuits & Alerts
Communication & teamwork common “agents of loss” in surgical lawsuits
Failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module1/module1_fall-prevention.docx
March 01, 2013 - We create a culture that focuses on safety, and we are constantly aware of the possibility of failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange.docx
July 12, 2017 - We create a culture that focuses on safety, and we are constantly aware of the possibility of failure
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pbrn.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/guide.html
September 01, 2017 - We create a culture that focuses on safety, and we are constantly aware of the possibility of failure
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pbrn.ahrq.gov/sites/default/files/publications/files/redtoolkitforms.pdf
September 01, 2012 - PATIENT: Yes, I was admitted with congestive heart failure. It was the second time this year. … CALLER: Could you tell me your understanding of congestive heart failure? … Since you left the hospital, do
you feel your congestive heart failure has improved, worsened, or not … Patient Name
Name of Contact 1
Name of Contact 2
Examples of Diagnosis Pages
Congenitive Heart Failure
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
May 01, 2017 - AHRQ Safety Program for Perinatal Care
Labor and Delivery Unit Safety
Labor and Delivery Unit Safety
SAY:
The “Labor and Delivery Unit Safety” bundle provides information on the key safety elements concerning four specific situations encountered in labor and delivery, and the importance of a comprehensive unit-based …
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pbrn.ahrq.gov/teamstepps/webinars/previous-webinars-2016.html
June 01, 2017 - SHARE:
More topics in this section
TeamSTEPPS®
About TeamSTEPPS®
Curriculum Materials
TeamSTEPPS® 2.0 Online Master Trainer Course
Research/Evidence Base
TeamSTEPPS® Webinars
Previous TeamSTEPPS Webinars: 2016
…
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pbrn.ahrq.gov/cpi/about/mission/strategic-plan/CHStratPlan.html
December 01, 1999 - Strategy 5.1.4 : Monitor implementation and evaluate success or failure of the inclusion policy.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-april2015.pptx
January 01, 2015 - 1 05.2 Page ‹#›
TeamSTEPPS®
TeamSTEPPS for Code Blue Teams
Slide ‹#›
Assertive Statement, CUS
Failure