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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
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www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
September 01, 2016 - culture from one of blaming
individuals for errors to one in which errors are treated
not as personal failures
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preventiveservices.ahrq.gov/teamstepps-program/welcome-guides/new-trainers.html
July 01, 2023 - While reflecting on patient harms that resulted from systemic and teamwork failures can have value, consider
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses4.html
August 01, 2022 - This case revealed numerous system failures that contributed to the initial misdiagnosis and needless
-
ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses6.html
August 01, 2022 - Communication failures: an insidious contributor to medical mishaps.
-
preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Practice “collective mindfulness,” understanding that even small failures in safety protocols or processes
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.docx
May 01, 2017 - Slide 21
SAY:
Adverse events are often system failures.