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pcmh.ahrq.gov/teamstepps/instructor/fundamentals/module5/igsitmonitor.html
March 01, 2019 - Return to Contents
STEP
Say:
In a busy health care environment, knowing which elements you … Return to Contents
Status of the Patient
Say:
In a health care setting, the most obvious element … Health care providers are just as prone to human error as the general population. … The health care environment is dynamic, requiring team members to continually reassess situations to
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pcmh.ahrq.gov/teamstepps/rrs/rrs_slides/rrsslides.html
July 01, 2018 - Qual Saf Health Care . 2004;13(4):251-254. … The organization selects a suitable method that enables health care staff members to directly request … (Photo of patient and health care professional in a hospital room.) … Assessment (PRA)
Reactive approaches
Root Cause Analysis (RCA)
(Text box at right describes the integrated … Integrated Sensemaking Approach
What can go wrong?
What are the consequences?
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/trainershandouts_all.docx
September 01, 2012 - clinical consequences.7
Despite evidence that LEP patients are safer with professional interpreters, health … Intl J Qual Health Care 2006;18:383-8.
2. Flores G. … The impact of medical interpreter services on the quality of health care: a systematic review. … Health Affairs Blog 2008 Nov 19. … Ensure that interpreter is fully informed and integrated into team
Who?
How?
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pcmh.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
December 01, 2012 - Int J Qual Health Care 2007 Apr;19(2):60-67. Epub 2007 Feb 2. … Crossing the quality chasm: a new health system for the 21st century. … Am J Public Health 2005;95(9):1561-7.
Price-Wise G. … Health Affairs Blog 2008 Nov 19. … Berkeley: University of California School of Public Health; 2010.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-section-6a.pdf
July 27, 2017 - care they need when they need it:2
In a survey of insured adults under 65, 27 percent of those with health … 28 percent of women in fair or poor health reported delaying care or failing to
receive care because … and represented 51 percent of quality of care complaints) as
well as a survey of satisfaction with behavioral … health. … Quality Improvement/Preventive Health Activity Summary: Improving Satisfaction with Appointment
Access
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pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
August 01, 2022 - Department of Health and Human Services. … Department of Health and Human Services. … Studies in Health Technology and Informatics. Vol. 263. … https://ebooks.iospress.nl/volume/applied-interdisciplinary-theory-in-health-informatics-applied-interdisciplinary-theory-in-health-informatics … The Quality in
Australian Health Care Study.
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pcmh.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/practices.html
January 01, 2013 - Any documentation strategy should be carefully integrated into workflow, so as not to become just another … Because each patient has a unique risk profile that needs to be integrated with care for the condition … Stud Health Technol Inform 2009;146:455-9. … Read more about how one health care system that uses an electronic health record developed a new system … Health care protocol: prevention of falls (acute care). 3d ed.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/assemble/assembleteam.docx
August 24, 2012 - the CUSP team has resources to fix problems, and
· Makes rounds and meets monthly with members of the health … Health care providers from the unit who will be engaged should also be actively recruited.
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pcmh.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
July 01, 2022 - Setting
Quality Measures
Reports
AHRQ-Funded Patient Safety Research Featured in Health … Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration ( … Christiana Care Health System: Safety Mentor Program ( PDF , 501 KB ) Michele Campbell, et al. … News Media and Health Care Providers at the Crossroads of Medical Adverse Events ( PDF , 129 KB ) … Personal Health Records to Improve Health Information Exchange and Patient Safety ( PDF , 803 KB )
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - • The 1999 Institute of Medicine report To Err is Human: Building a Safer Health System
focused the … attention of the health care community and the public on the estimation that
between 48,000 and 98,000 … Healthcare organizations must systematically identify
and mitigate patient safety risks and hazards with an integrated
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pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/nurse-role-dxsafety.pdf
September 02, 2022 - Department of Health and Human Services. … Department of Health and Human Services. … interprofessional consensus group convened by SIDM in 2019.52
Patient Safety Vignettes
Vignette 1: Behavioral … Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, … E-learning for
health professionals.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/topics/managing-interruptions-improve-diagnostic-decisionmaking.pdf
December 29, 2022 - Interruptions are an inevitable occurrence in health care. … We then consider sev-
eral empirically tested strategies from the fields of health
care and cognitive … While there is ample
research on the effects of interruptions within other realms of
health care (e.g … � In a particular health care setting, is there
consensus around which messages are/are
not urgent? … Inform Health Soc Care 2021;46(3):263–272.
8. Coiera E. The science of interruption.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_tools.docx
November 16, 2011 - Items marked with an asterisk (*) can be integrated into your hospital’s electronic health record with … Reference: Adapted from Singapore Ministry of Health Nursing Clinical Practice Guidelines on Prevention … program should include:
Individually-tailored fall prevention strategies
Education to patient/family and health … Education programs should target primarily health care providers, patients, and caregivers.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.pdf
February 12, 2014 - B-5-9
Situation
Monitoring STEP
Slide
SAY:
In a busy health … TeamSTEPPS 2.0 | Situation Monitoring
STATUS OF THE PATIENT
SAY:
In a health … Health care providers are just as prone to human error as the
general population. … The health care environment is dynamic, requiring team members
to continually reassess situations to
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.pdf
January 28, 2011 - Qual Saf
Health Care 2009;18(6):424–8. … care and promotes patient and family advocacy in their health care
environment. … Health care practitioners listen to and honor patient and
family perspectives and choices. … Patients, families, health care practitioners, and health care leaders
collaborate in policy and program … liaison
supports the council and its members and helps ensure that council
activities are meaningfully integrated
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
May 01, 2017 - These techniques are being integrated into health care through programs such as TeamSTEPPS. … The first study listed is the original pilot study of the World Health Organization or WHO Surgical Checklist … Patients are harmed unnecessarily, and health care providers can deliver safer care to prevent these
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
August 20, 2015 - A process which has been integrated into the organizational culture is more likely to continue to produce … University of Michigan Health System. … University of Michigan Health System.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigstafftrain.pdf
November 19, 2008 - Intl J Qual
Health Care 2007;19(2):60-67. Epub 2007 Feb 2. … Finally, the interpreter can serve as a cultural broker, helping
health care providers understand the … during the entire patient
encounter, and (4) ensuring that the interpreter is fully informed
and integrated … Some possible reasons include the
traditional hierarchy of health care, strong personalities of some … health care providers, and previous negative experiences with
speaking up.
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pcmh.ahrq.gov/sites/default/files/attachments/pcpf-module-21-leadership.pdf
September 01, 2015 - Supporting Practice Leaders
Agency for Healthcare Research and Quality
Advancing Excellence in Health … Department of Health and Human Services. … The role of conversation in health care
interventions: enabling sensemaking and learning. … Within larger health care systems, which may include multisite
practices as well as other health care … The role of conversation in health care interventions: enabling
sensemaking and learning.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/stafftrainhandouts_all.docx
September 01, 2012 - clinical consequences.7
Despite evidence that LEP patients are safer with professional interpreters, health … Intl J Qual Health Care 2006;18:383-8.
2. Flores G. … The impact of medical interpreter services on the quality of health care: a systematic review. … Health Affairs Blog 2008 Nov 19. … Ensure that interpreter is fully informed and integrated into team
Who?
How?