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www.ahrq.gov/teamstepps-program/curriculum/intro/teach/half-day.html
August 01, 2023 - Half-Day Training Content
Components you can include in the Introduction for a half-day training include:
Quick introductions of trainers and participants : 3 minutes
Abbreviated teamwork exercise : 10 minutes
Course objectives, overview, resources, and rationale : 2 minutes
Patient story video and re…
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psnet.ahrq.gov/node/33567/psn-pdf
June 15, 2024 - Handoffs
June 15, 2024
Handoffs and Signouts. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/handoffs
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Backgroun…
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www.ahrq.gov/patient-safety/resources/learning-lab/yale-center-long-desc.html
June 01, 2020 - Yale Center for Healthcare Innovation, Redesign, and Learning
Long Description
Principal Investigator: Sarwat Chaudhry, M.D., Yale University, New Haven, CT
AHRQ Grant No.: HS23554
Project Period: 09/30/14–09/29/19
Description: The goal of CHIRAL was to improve transitions of care. Patients being …
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www.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
February 01, 2024 - Improving the Safety of Diagnosis and Therapy in the Inpatient Setting
Principal Investigators: Anuj K. Dalal, M.D., and David Bates, M.D., MSc., Brigham & Women’s Hospital, Boston, MA
AHRQ Grant No.: HS26613
Project Period: 09/01/18-06/30/22
Description: The overall goal of this learning lab was to i…
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - considerably.( 9 ) Certain comorbidities that impact on mortality (such as morbid obesity, dementia, and heart failure … They had some problems with young men having organ failure in a drug trial, and they'd had some excess
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - The patient’s care was adversely affected by delays in diagnostic evaluation, failure to recognize the … often represents a manifestation of metabolic derangements (e.g., hypoxia, acidosis, kidney or liver failure
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide3.html
October 01, 2017 - The failure to have clear admission documentation led to an increase in the documentation of hospital-acquired … ongoing complex medical care and a need for management of advanced Parkinson’s disease, dysphagia, and failure
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
June 01, 2016 - Proactive harm avoidance work is done utilizing the failure mode and effect analysis model. … program embraces the high reliability concepts of resilience, reluctance to simplify, preoccupation with failure
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psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
March 30, 2020 - I would say that I spent the most time on the sections related to failure to rescue and sepsis, as I … While not a failure of a hospital process, these nevertheless were a risk or potential risk that impacted
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - human factors.15,16 These errors are associated with prescribing (incomplete or
contradictory orders, failure … include activation of PCA by
others (usually well-meaning family, or “PCA by proxy”) and equipment failure
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - continue.2
While a large published series of all types of diagnostic errors in medicine found that “failure … to consider” a
particular diagnosis was the leading contributor to misdiagnosis, failure to consider
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - have shown that with outpatient or home-based palliative care, patients with cancer, advanced heart failure … WebM&M Cases
Recurrent Hypoglycemia: A Care Transition Failure
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - AI systems are trained on training data; in other words, on patterns they’ve seen before, on known failure … They can offer robust solutions, but robust solutions can become brittle toward new vectors of
failure
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017075-sequist-final-report-2010.pdf
January 01, 2010 - Rather than a
failure of integration into the clinical workflow or problems with usability, it may be … considers a substantial investment to support the broad implementation of
electronic health records, the failure
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - listed several other major techniques, such as human factors engineering, root cause analysis, and failure … Each "failure" brings us a step closer to understanding how practices can be successfully implemented
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - I would say that I spent the most time on the sections related to failure to rescue and sepsis, as I … While not a failure of a hospital process, these nevertheless were a risk or potential risk that impacted
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Fricton_21.pdf
April 17, 2008 - Stratis Health,
and Avenet Web Solutions to implement PHRs in a defined population of congestive heart
failure … Use of a
patient-accessible electronic medical record in a
practice for congestive heart failure: Patient
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psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
February 26, 2025 - RW : In Silicon Valley, every successful entrepreneur has a great failure story. … What macro lessons from that failure have been important to you in your career?
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www.ahrq.gov/sites/default/files/2024-09/segall-report.pdf
January 01, 2024 - Results: The difference between patient loads was not statistically significant, but frequency of failure … Accordingly, the
frequency of failure to meet a response time goal of less than 20 seconds was significantly
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - Improve diabetes
management, improve congestive heart failure management, and you decrease rates of … would have patients
that had diabetes, COPD [chronic obstructive pulmonary disease], congestive heart failure