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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
January 01, 2017 - The Timeline to Diagnostic Safety SIDM -Research as a Priority
The Timeline to Diagnostic Safety
SIDM - Research as a Priority
Mark L Graber MD FACP
Senior Fellow – RTI International
Professor Emeritus - SUNY Stony Brook
Founder and President – SIDM
graber.mark@gmail.com
VISION: Creating a world
where no pat…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/appendectomy-booklet.pdf
November 01, 2023 - To understand what happened, let’s take a look at the diagram below of the belly area. … It depends on what happened during surgery
and on your health before surgery.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
August 01, 2022 - Stress that the purpose of the interview is to learn more about what happened and how to make the system … Can you tell me about your understanding of what happened?" … "I would like to learn more about what happened.
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ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-module3-speaker-notes.html
February 01, 2023 - Ask yourself: Could this have happened in my ICU?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module2/2_ts_office_structure.pptx
January 20, 2006 - PowerPoint Presentation
for
Office-Based Care
Team Structure
TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
Page ‹#›
RRS
1
Care Team Structure
TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
Page ‹#›
Office-Based Care
Let’s Talk About Your Team
What does it look like?
Who are the team members?
When do you intera…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
April 01, 2016 - Stress that the purpose of the interview is to learn more about what happened and how to make the system … Can you tell me about your understanding of what happened?” … 2) “I would like to learn more about what happened. … What happened during the handoff? … Was
there anything that happened during the
handoff that may have contributed to the
event?
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ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/phys-championsgd/appa.html
October 01, 2015 - Skip to main content
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module4-leadership.pptx
January 05, 2022 - Module 4: Leadership
Module 4
Leadership To Improve Diagnosis
TeamSTEPPS® for Diagnosis Improvement
Welcome to the TeamSTEPPS for Diagnosis Improvement course. This presentation will cover Module 4, Leadership To Improve Diagnosis, that you will review as the course facilitator.
Individuals who plan to take the…
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ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/fundamentals/module8/igchangemgmt.html
March 01, 2019 - What happened? Was it successful? Why?"
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ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/guides/implguide-pt4.html
October 01, 2015 - of CAUTI is identified, the staff are more likely to take note and become interested in knowing what happened
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ce.effectivehealthcare.ahrq.gov/talkingquality/plan/environment.html
June 01, 2016 - What happened to it?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/sustainability-guide.pdf
September 01, 2015 - questions and documenting the answers to
help ensure resolution and support future learning:
What happened … This way of
looking at safety encourages staff to learn what happened and why, and how to take action
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_2-speaker-notes.docx
September 01, 2015 - AHRQ Safety Program for Reducing CAUTI in Hospitals
Preventing CAUTI in the ICU Setting
Module 2: Urinary Catheter Maintenance
SAY:
In Module 1, we discussed the indications for an indwelling urinary catheter, the causes of catheter-associated urinary tract infections or CAUTI in the intensive care unit or ICU, as…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/actionplan-trip-facguide.docx
January 01, 2017 - What actually happened?
What did you learn?
What are your next steps?
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ce.effectivehealthcare.ahrq.gov/health-literacy/professional-training/informed-choice/audio-script.html
September 01, 2020 - Skip to main content
An official website of the Department of Health and Human Services
Careers
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_vbac-abpain.docx
May 01, 2017 - Sample Scenario for Magnesium Toxicity In Situ Simulation
AHRQ Safety Program for Perinatal Care
Sample Scenario for Severe Abdominal Pain/VBAC In Situ Simulation
Sample Scenario for Severe Abdominal Pain/VBAC In Situ Simulation
Purpose of the tool: The Severe Abdominal Pain/VBAC (vaginal birth after cesarean) In Si…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
August 01, 2021 - Did You Know, Safety Infographic
Did you know...
57%
of all diagnostic
failures happen in
ambulatory care.1
1 in 20
patients who attend a
primary care appointment
this year will experience a
diagnostic error.2
79% of diagnostic
errors are related to the
patient-clinician encounter.3
up to
56%
of these …
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-facilitator-guide.pdf
November 01, 2019 - What happened?
2. Why did it happen?
3.
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ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-3.html
June 01, 2021 - Skip to main content
An official website of the Department of Health and Human Services
Careers
Contact Us
Español
FAQs
Search all AHRQ sites
Search small
Search
Menu
…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/patient-family-centered-care-040913.ppt
October 01, 2015 - Standardize
Eliminate steps if possible
Create independent checks
Learn when things go wrong
What happened