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201. The Challenge and Potential for Assuring Quality Health Care for the 21st Century | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/quality-measures/21st-century/index.html
     June 01, 2018 - Underuse of Services: The failure to provide a needed service can lead to additional complications, … Overuse of Services: Unnecessary services add costs and can lead to complications that undermine the … Overuse of antibiotics has been shown to lead to resistance and as much as $7.5 billion a year in excess … Misuse of Services: Errors in health care delivery lead to missed or delayed diagnoses, higher costs … still an unacceptable rate of errors; one study estimates that preventable errors in hospital care lead

202. Improving Value and Efficiency in Hospitals and Medical Offices: A Resource List for Users of the AHRQ SOPS Value and Efficiency Supplemental Items (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/valueresourcelist.pdf
     January 01, 2019 - approach to change that has been found to be useful in developing specific ideas for changes that lead … engagingfamilies/index.html Research shows that when patients are engaged in their healthcare, it can lead

203. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - They encompass most of the factors that lead to a particular CDR or, as is more likely, an aggregate … Changing conditions and interpersonal conflict in the workplace may lead to temporary or ongoing changes … Finally, the phenomenon of “group think” can lead to a variety of behaviors in team members that are … Finally, the disruption of circadian rhythms that results from shiftwork may lead to mood disturbances … It should follow that if we are able to delineate the principal factors that lead to those CDRs that

204. TeamSTEPPS® Helps St. Louis Hospital Keep C-Section Rate Low | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/201904.html
     June 01, 2019 - For every labor and delivery patient, the charge nurse and chief resident lead an interdisciplinary team … Labor and delivery units are high-risk environments where one miscommunication can lead to care breakdowns

205. Implementing Automatic Referral | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/takeheart/training/implementing-automatic-referral/index.html
     April 01, 2023 - Q&A Epic Q&A Cerner Q&A Stephen Hines , Ph.D., TAKEheart's Training and Technical Assistance Lead … Session (PDF, 2 MB) Epic Q&A Stephen Hines , Ph.D., TAKEheart's Training and Technical Assistance Lead

206. Research in Shared Decision Making | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/sdm/research/index.html
     May 01, 2023 - This model focuses on the "problems that lead patients and clinicians to be interacting in the first … opportunities for improvement and advancement, and occasionally invite other experts in the field to lead

207. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - However, safety science shows that these types of recommendations do not consistently lead to sustained … develop skills necessary for conducting successful event reviews, improve discovery and learning, and lead … Just Culture "People make errors, which lead to accidents. Accidents lead to deaths. … It is essential that employees feel comfortable sharing openly, as that will lead to a more accurate … Very often the answer to a question will lead you to another question.

208. TeamSTEPPS 2.0 Overview (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/ts2-0ltc_overview.pdf
     April 24, 2017 - designed to help you develop and deploy a customized plan to train your staff in teamwork skills and lead … It may be necessary, for example, to lead a discussion about the changes to help correct misconceptions

209. Learn From Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
     February 01, 2017 - nurses, doctors, and other clinicians find frustrating because it affects their workflow and could lead … Anything that might lead to preventable patient harm can be considered a defect. … can lead to the implementation of an intervention which ensures that necessary supplies are available … Why did one contributing factor lead to another contributing factor? … And why did the next factor lead to the next?

210. Challenges in Approaching Diagnostic Safety Unique to Children | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-2.html
     August 01, 2023 - conditions, clinician risk tolerance contributes significantly to variation in testing practices and can lead … of overtesting, although not an MDO, nonetheless exposes children to possible harm if test results lead … The generally low likelihood of diagnosing serious illnesses may also lead clinicians toward opposite

211. Understanding the Role of Health Care Facility Design in the Acquisition and Prevention of HAIs | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/haidesign/haidesign-summary.html
     April 01, 2018 - infectious agents can be brought into hospitals by colonized or infected hosts or other external sources and lead … Contact with contaminated surfaces can lead to transmission of pathogens, with health care workers often … suboptimal maintenance of the built environment can increase the risk of transmission of pathogens and can lead … be easy to merge discipline-specific perspectives through collaboration, but such open dialogue will lead

212. Surgical Safety Team Roles and Responsibilities Tool | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/tools/applying-cusp/surgical-roles.html
     December 01, 2017 - Implement Teamwork Tools Who will lead the implementation of briefings, debriefings, and other teamwork … Implementation of Practice Changes Who will lead efforts to align practice with evidence-based guidelines

213. Core Principles for the PCA Diagnostic Team | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-6.html
     July 01, 2023 - Ideally, these AI alerts will lead to the patient engaging with the healthcare system and providing the … This information could lead to interventions to prevent falls. … For instance, an AI-based system designed to identify intracranial hemorrhage on CT images may lead radiologists … This feedback may lead to improvement of model performance and usability, as well as iterative updates

214. Webinar Transcript - The National Quality Strategy and the Public Sector: Federal Agency Alignment to the Six Priorities | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/workingforquality/events/webinar-federal-agency-alignment-to-the-six-priorities.html
     November 01, 2016 - Nancy Wilson, Executive Lead for the National Quality Strategy, will give a brief overview of the Strategy … He has diverse health care interests, including lead poisoning, vaccine preventable disease, tobacco

215. TeamSTEPPS 2.0: Introduction (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/introduction.pdf
     February 28, 2014 - designed to help you develop and deploy a customized plan to train your staff in teamwork skills and lead

216. Strategy 2: Communicating to Improve Quality (Tool 3) (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-b.docx
     April 21, 2014 - Share the timeline of how this work will unfold over the course of this program Your Role as the Team Lead

217. PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module-2-slides.pptx
     September 01, 2015 - ‹#› AHRQ Safety Program for Reducing CAUTI in Hospitals 2 Question What did you notice that could lead

218. TeamSTEPPS for Office-Based Care: Implementation Planning | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/officebasedcare/module11/office_impplan.html
     September 01, 2015 - Continuous improvement includes going back to training to lead to more culture change. … Develop an Implementation Plan Timeline Step Lead Completion Date Resources Required 1. … Communication Plan       Return to Contents Slide 18: Change Team Meetings Purpose Lead

219. Communication Assessment Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5.html
     August 01, 2022 - Communication and Optimal Resolution (CANDOR) Implementation Team, Disclosure Lead(s), Disclosure Communicators

220. Preventing CAUTI in the ICU Setting Facilitator’s Guide Transcript | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-transcript.html
     February 01, 2023 - and 7 percent per day, so we know that unnecessary culturing without signs or symptoms of UTI could lead … This can lead to inappropriate use of antibiotics. … Slide 4 You should have identified three issues that can lead to the development of a CAUTI: The … Not attaching the catheter to the leg can lead to urethral irritation. … X was on a chronic diuretic, which would lead to high urinary output, it was not being adjusted.