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401. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
     June 15, 2003 - reporting, timely and effective information sharing, and adoption of real-time practice changes that lead … Reporting systems To identify system failures & unsafe conditions that could lead to system failures … and individuals to (1) identify and learn from past system failures and unsafe conditions that could lead … transforms knowledge into learning through the creation of new standards, processes, and practices that lead … • Hospital staff tracking information for all systems failures and unsafe conditions that could lead

402. PowerPoint Presentation (ppt file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK3_P3T5-Training_Slides_for_Nursing_Home_Nurses_Phase_3.ppt
     May 01, 2014 - The use of antibiotics can lead to problems.

403. Integrating-Teamwork-Tools-Into-Cusp-Efforts-Transcript (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/integrating-teamwork-tools-into-cusp-efforts-transcript.docx
     April 07, 2015 - Shannon is the New Jersey State Lead for several CUSP projects including Stop CAUTI, BSI, CUSP for MVP … Varying communication styles, which can sometimes lead to conflict among team members. … These barriers can lead to issues with communications and care planning for our patients. … Also, potential patient safety issues which, as we know, can lead to harm and adverse outcomes.

404. D. Subcommittee Member and Staff Biographies | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/iomracereport/reldataapd.html
     May 01, 2018 - In addition, he is co-lead for Aetna's Racial and Ethnic Disparities in Health Care Initiatives. … He also serves as the corporate clinical lead representing the chief medical officer in crisis and disaster … preparedness, as well as the corporate clinical lead for pandemic planning at Aetna.

405. Module 11 Instructor Slides (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module11/ts2-0ltc_module11_slides_implementation.pdf
     June 09, 2017 - Develop an Implementation Step Lead Completion Date Resources Required 1. … Plan TEAMSTEPPS 05 2 Implementation Planning Change Team Meetings Purpose Lead

406. Presentation: Program Overview
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel.pptx
     December 01, 2017 - undergoing inpatient surgeries develop complications, and these complications prolong hospital stays, lead … These individuals should lead the surgical safety team. … leader plays a critical role in ensuring the hospital physicians are on the same page as the project lead … , nurse lead, surgeon lead, and executive partner along with other team members List team member names … Include a team lead, a nurse lead, a surgeon lead, and an executive partner along with other team members

407. Community Pharmacy Survey on Patient Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/toolkit/PharmSOPSform.pdf
     June 06, 2018 - Pharmacist (including pharmacy manager, lead pharmacist, pharmacist-in-charge, staff pharmacist) b … Pharmacy technician (including lead technician and staff technician) c.

408. Antibiotic Stewardship Program Development: Part 2 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/program-part2-facilitator-guide.pdf
     November 01, 2019 - The final section of this presentation will discuss an approach to lead change within your institution

409. Medical Home Transformation in Pediatric Primary Care – What Drives Change? | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/ncepcr/research-transform-primary-care/transform/profile/cooley.html
     August 01, 2018 - Provider Satisfaction Lead clinicians and care coordinators described an enhanced sense of personal … Family participation was a lead driver of PCMH transformation.

410. Guide for Developing a Community-Based Patient Safety Advisory Council | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncil2.html
     April 01, 2018 - developed on the premise that a collaborative process, with patients and providers working together, would lead

411. Special Considerations for Measurement of Diagnostic Safety | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-2.html
     June 01, 2020 - The knowledge created by measurement will also lead to changes in policy and practice to reduce diagnostic … current external accountability metric, HCOs should focus on implementing measurement strategies that can lead … assumptions that should guide and facilitate institutional practices for measurement of diagnostic safety and lead

412. PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - doesn’t communicate, or the communication doesn’t meet the patients’ or families’ expectations, it may lead … Potential decrease in adverse events being litigated, which can lead potentially led to lower malpractice … Resolution should lead to a settlement of issues related to the adverse event, but doesn’t always lead

413. TeamSTEPPS for Office-Based Care: Change Management | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/officebasedcare/module9/office_mgmt-ig.html
     September 01, 2015 - Therefore, we recommend you lead the practice facilitators through a discussion, rather than lecturing … Lead a discussion in which participants present their best practices for organizational change. … Together the Guiding Team Say: For the change effort to be successful, a powerful group must lead … Most organizations have a guiding coalition , or team of individuals who lead the change efforts, already

414. Case Report on Ambulatory Safety and Quality (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-casereport.pdf
     September 05, 2017 -  What happens when the lead person in unavailable?  What exceptions are there? …  Is there a lead staff person that is responsible for the process? …  What happens when the lead person in unavailable?  What exceptions are there? … The clinic’s point of contact (office manager or lead clinician) will be the main contact for this … The contact person will assist in assembling a local practice team consisting of a lead clinician,

415. TeamSTEPPS 2.0: Essentials Course (Instructor Guide) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/igessentials.pdf
     March 11, 2014 - to the health care environment, a high- risk, high-stakes environment in which poor performance may lead … The team understood what specific factors could lead to C-section and Dr.

416. Strategy 6L: Planned Visits | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/coordination-of-care/strategy6l-planned-visits.html
     March 01, 2020 - Effective planned visits can lead to better clinical control of the illness (e.g., improvements in indicators … They may also lead to fewer acute care visits, reduced costs, and greater patient satisfaction.

417. Identifying Key Areas for Delivery Systems Research | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/practiceimprovement/delivery-initiative/casalino/index.html
     December 01, 2017 - Identify incentives likely to lead to creation of these organizations and to movement of providers into … Slide 14 Key research area #2 Analyses of ways to structure incentives so that they lead to:

418. Executive Summary | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stprasumm.html
     April 01, 2013 - ambulatory surgery environment, and examining single-point failures as well as combinations of events that lead … , dependencies and interactions) among the multiple risk points to understand how they collectively lead

419. Executive Summary | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/clabsi-final/clabsifinalsum.html
     January 01, 2013 - associations or State sponsors recruited and coordinated efforts with member hospitals and assigned a lead … staff person, most often the senior quality manager in the association, to become the "State lead" to

420. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-intro-facguide.docx
     January 01, 2017 - underdistention of other areas occurs), and barotrauma, which causes complications from high pressure that can lead … This leads to stiff lungs, and can lead to overinflation and underinflation in air distribution across … Slide 18 The Problem with Large Tidal Volumes (Vt) SAY: Larger tidal volumes could also lead to barotrauma … Low tidal volumes can lead to atelectasis and, of course, that can lead to shunt. … 39 Respiratory Rate SAY: The low tidal volume strategy sometimes requires an approach that will lead