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2361. Usability Testing and the Relation of Clinical Information Systems to Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Rogers.pdf
      January 01, 2003 - scanned information associated with the medication did not match the patient’s medication orders, a pop-up … A pilot test often is conducted, due to the complexity of the information system set up and the clinical

2362. Identifying Barriers to the Success of a Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
      March 01, 2004 - Follow-up reminders were sent 2 weeks after the first survey distribution. … Other industries administering mail surveys with no incentive and no follow-up or reminder letter typically

2363. Meeting Minutes, November 2016 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2016-11-nac/nacmtg1116-minutes.html
      August 01, 2017 - Bindman agreed, noting that AHRQ is investigating ways to speed up the process. Dr. … Administration is considering system change and partnerships, which help with implementation and scale-up

2364. Module 2: Senior Leader Engagement: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/mod2-facguide.html
      March 01, 2017 - leaders who lead by example, involve the whole team, strive for continuous improvement, lift others up … Part of this accountability requires that the leader encourages the team to speak up to identify concerns

2365. How are CHIPRA quality demonstration States supporting the use of care coordinators? | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight09.html
      July 01, 2014 - deliberate effort to match care coordinators with practices, the coordinators in the six States make up … Many practices found it easier to stay up to date on their patients, tailor visits more precisely to … Providers attributed these improvements to the care coordinators’ tracking of, and following up with, … Sign up for email updates from the national evaluation team .

2366. A Patient Safety Program & Research Evaluation of U.S. Navy Pharmacy Refill Clinics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Reige.pdf
      March 01, 2004 - This approach also opened up more appointments for acutely ill patients, further expediting the identification … patient Refill request is within reasonable time limit Yes, contact provider No, follow … For example, a patient on a diabetic medication who did not follow the instruction to take the prescription … with food could end up with an upset stomach and nausea. … The additional ramp-up time would also would help physicians and nurses time to become accustomed to

2367. 105-What-Are-The-4-Es-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/105-what-are-the-4-es-notes.docx
      April 01, 2025 - Slide 3 Case Example: Regional Hospital SAY: The following slides will follow a hypothetical case … The key to an effective team is to stay on top of issues identified and to follow through until resolution … There are always many contributory factors in healthcare that had to line up for an error to make their … embedding the new practices into daily routines and ensuring that personnel can and will continue to follow … best for their staff and patients in different settings, and ultimately make it easier for them to follow

2368. A Conceptual Framework for Studying the Safety of Transitions in Emergency Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Behara.pdf
      January 01, 2004 - Furthermore, the patients flow in a “jumbled” fashion as they do not usually follow a predetermined … Relationships among handover genres Point A represents a case “all wrapped up and tied with a bow … “work in progress” and “all wrapped up and tied with a bow.” … Cook has used the “spinning up” metaphor to describe this phenomenon (personal communication, Richard … the handover provides just enough of the relevant picture so that the oncoming caregiver can “spin up

2369. Final Progress Report: Workshop on Consumer Engagement in Selected Patient Safety Topics (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/hatlie-report.pdf
      January 01, 2024 - expectations  Accountability—the committee has to come to some form of closure  Accountability—for follow … up and action 8. … An identified team needs to be formed, possibly with an executive sponsor to ensure delivery and follow … • Tools are developed and distributed to clinicians and patients • Patients show up with advocates more … term): Establish criteria 17 4.2 Set definitions and benchmarks 4.2.1 Measure (short term): Set up

2370. The Mobile Mock Operating Room: Bringing Team Training to the Point of Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Paige_6.pdf
      January 24, 2008 - considerations in adapting the VOR to an MMOR configuration included easy and efficient transport, set up … of our center-based simulation programs, issues related to technical function, transportation, set-up … Each training session lasted up to 3 hours and included two simulation-based scenarios, each followed … Set-up in the OR and functional testing was easily completed within 20 to 30 minutes.

2371. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.docx
      August 01, 2010 - updated on that plan, patients feel more secure, and are more likely to participate in their own care and follow … If the patient speaks up and asks the visitor to remain, then the report can proceed. … If these concerns come up frequently and prevent nurses from conducting the report at the bedside, consider … This way, the choice is up to the patient rather than an assumption by the nurses. … Anne Arundel Medical Center also provided mechanisms for staff to give feedback, including setting up

2372. CAHPS Health Plan Survey Child Medicaid Survey 5.0 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hp/Child_Med_Eng_HP50_2155a.pdf
      September 01, 2015 - In the last 6 months, did you make any appointments for a check-up or routine care for your child … In the last 6 months, how often did you get an appointment for a check-up or routine care for your … A personal doctor is the one your child would see if he or she needs a check-up, has a health problem

2373. Presentation: Program Overview
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/actionplan-trip-slides.pptx
      January 01, 2017 - believe the increase in workload to mobilize patients is going to prevent us from getting patients up … believe the increase in workload to mobilize patients is going to prevent us from getting patients up … The preventability of ventilator-associated Events: The CDC Prevention Epicenters' Wake Up and Breathe … The preventability of ventilator-associated Events: The CDC Prevention Epicenters' Wake Up and Breathe … The preventability of ventilator-associated Events: The CDC Prevention Epicenters' Wake Up and Breathe

2374. View Survey (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/member-survey-nw.pdf
      January 01, 2014 - through face-to-face discussions in this practice Members of this practice are able to bring up

2375. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-staff-engagement-facguide.docx
      January 01, 2017 - like if everyone—all the staff, the nurses, the physicians, the technicians—were empowered to speak up … SAY: How comfortable people are speaking up represents our teamwork climate. … SAY: The way we feel when we show up at work profoundly influences how well we do and what we do at work

2376. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/using-checklists/checklistandauditslides.pptx
      September 03, 2014 - model’s six interventions 7 Checklist and Audit Tools SAY: The six interventions that make up the … But subtle changes in practice can add up to major omissions, leaving the opportunity for infections. … Staff can review checklists with patients or give them copies to follow. … unannounced if possible 30 Checklist and Audit Tools SAY: When conducting audits, it is important to follow … Without adding overtime, the staff was able to extend turnover time enough to follow procedures more

2377. Presentation: Auditing Your Briefings and Debriefings
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing.pptx
      December 01, 2017 - We also discussed key elements of a successful briefing process, including a thorough system to follow … up on defects identified by the surgical team. 1 Learning Objectives Recap the briefings and debriefings … ASK: Were expectations set for people to be assertive in speaking up? … Spoke up or participated in the conversation? What issues were raised? … Observing whether people were pausing, speaking up and participating was harder.

2378. Final Progress Report: Improving Warfarin Management in Competitive Healthcare (pdf file)
      www.ahrq.gov/sites/default/files/2024-04/levett-report.pdf
      January 01, 2024 - weeks of initiation of therapy Medical Records Database X X 8 3 Failures of patient to follow … Therefore, comparison will be conducted with follow-up CAT Clinic surveys. … Full Group ⚫ Future View – Year 2 of PIPS Grant – September 25th, 3-5 PM Next session ⚫ Wrap-up … Clinic 5:15 Update on CRHA Activity 5:25 Small Group Activity 5:40 Report Out 5:55 Wrap-Up … 5:40-5:55 Report out of Small Group Activity 5:55-6:00 Wrap-Up 6:00 Adjourn Appendix C

2379. Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: 2021 User Database Report Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2021-HSOPS2-Database-Report-Part-I-508-rev0921.pdf
      January 01, 2021 - In addition to items that make up these composite measures, the survey includes two single- item measures … Communication Openness % Most of the time/Always In this unit, staff speak up if they see something … staff in this unit see someone with more authority doing something unsafe for patients, they speak up … (Item C5) 72% 7.48% 55% 63% 67% 72% 77% 83% 91% When staff in this unit speak up, those with more … An example of a positively worded item is C4—In this unit, staff speak up if they see something that

2380. Build a Business Case for Quality Improvement: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/cusp/build-business-case-slides.html
      February 01, 2017 - Slide 11: Ventilator-Associated Events Successes CDC Epicenters Wake Up and Breathe Collaborative … Arrow pointing up covering SAT and SBT increases.