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www.monahrq.ahrq.gov/teamstepps-program/curriculum/communication/overview/index.html
June 01, 2023 - ownership
Situation Awareness & Contingency Planning
Know what’s going on
Plan for what might happen
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www.monahrq.ahrq.gov/hai/tools/surgery/guide-surg-comp.html
December 01, 2017 - Identification and Mitigation Tool ( Word , 1.73 MB)
Understand where, when, and why workarounds happen
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www.monahrq.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
September 01, 2020 - Patient Safety Terminology
Medical errors*:
Medical errors happen when something that was planned … They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet … Most errors result from problems created by today's complex health care system, but errors also happen
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
July 01, 2018 - It is just by chance that more serious mistakes don’t happen around
here ........................... … My supervisor/manager overlooks patient safety problems that happen
over and over ................... … My supervisor/manager overlooks patient safety problems that happen over and over. … It is just by chance that more serious mistakes don't happen around here. … We are informed about errors that happen in this unit.
C5.
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www.monahrq.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-module2-speaker-notes.html
February 01, 2023 - In this scenario, the transporter didn’t understand what might happen because of wrong bag placement
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2018mosopsdatabasereport-part1-rev0921.pdf
April 01, 2018 - (F2)
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Mistakes happen more than they should in this office. … (E1R)
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They overlook patient care mistakes that happen over
and over. … This office is good at changing office processes to
make sure the same problems don’t happen again. … Mistakes happen more than they should in this
office. … They overlook patient care mistakes that happen
over and over.
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Tool_4_PPT_508.pptx
April 01, 2011 - collaboratively with patients and family members should make everyone clear about what should and should not happen … The doctor gives the order for discharge, but, this should not be a surprise or happen in a vacuum. … What needs to happen? Who is responsible? … As you play out the scene, the objectives are to make sure that:
Emily is fully aware of what will happen … As you play out the scene, the objectives are to make sure that:
Arnold is fully aware of what will happen
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www.monahrq.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/visual-comp-kit.html
June 01, 2017 - problems in your safety management that you can tackle (problems are gaps between what you want to happen
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www.monahrq.ahrq.gov/news/blog/ahrqviews/ltc-quality-measures.html
December 01, 2022 - and whether these gaps are reduced for all long-term care patients, since long-term care may not just happen
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www.monahrq.ahrq.gov/health-literacy/professional-training/shared-decision/workshop/about.html
September 01, 2020 - YES / NO
A change in clinical practice doesn't happen overnight.
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www.monahrq.ahrq.gov/teamstepps/officebasedcare/module4/office_lead-ig.html
September 01, 2015 - examples could be from your actual experience in the medical office or experiences that you imagine could happen … and key events that occurred and asks questions related to team performance, such as, Did everything happen
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/interview-protocol-pcip-staff-ny.pdf
August 23, 2018 - If you want to make a change in this practice how does that happen?
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
May 01, 2017 - several common themes
Defects or failures are clinical or operational events that you do not want to happen
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
May 01, 2017 - How Can These Errors Happen
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module2/ebteamstruct.pdf
January 01, 2012 - environment, including changing behaviors of team members; and have a shared understanding
of what should happen
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/tinsleyslides.pdf
September 01, 2015 - Underwood Surgery Center: Slide Presentation
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50
Underwood Surgery Center
Orlando, Florida
Terry Tinsley R.N., B.A.
Clinical Nurse Manager
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51
Underwood Surgery Center (USC)
• Physician owned multi-specialty surgery center
• Performs endoscopic procedures, surgeries
involving colon and rectal, …
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/motzslides.pdf
May 12, 2014 - Using the AHRQ Pharmacy Survey on Patient Safety Culture
© Aurora Health Care, Inc. © Aurora Health Care, Inc.
Pharmacy Survey on Patient Safety Culture
Jim Motz, R.Ph.
Specialty Pharmacy Program Manager
Aurora Pharmacy, Inc.
© Aurora Health Care, Inc.
Aurora Pharmacies Overview
• Integrated health sys…
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www.monahrq.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6p-service-recovery.html
April 01, 2022 - Responsiveness refers to the expectation that things should happen in a timely fashion and that people
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www.monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module9.pptx
March 07, 2019 - groups, and individuals in the organization who must feel the need for change for team training to happen … Module 9: Change Management
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The fourth phase in implementing change is to begin making it happen … This is making the change happen.
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www.monahrq.ahrq.gov/funding/process/grant-app-basics/hsubjects.html
August 01, 2018 - This may happen for various reasons, some related to the claims about the research protocol (e.g., for