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241. Communication: Severe Hypertension - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3_communication.pptx
     July 01, 2023 - To avoid making assumptions that can lead to error, you should verify in writing or orally any nonverbal … looking at an electrocardiogram would quickly tell the nurse the severity of the situation and might lead

242. Communication: Obstetric Hemorrhage - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
     July 01, 2023 - To avoid making assumptions that can lead to error, you should verify in writing or orally any nonverbal … looking at an electrocardiogram would quickly tell the nurse the severity of the situation and might lead

243. Situation Monitoring: Obstetric Hemorrhage - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_4-situation-monitoring.pptx
     July 01, 2023 - Ground Rules Host the debrief as soon as possible following a case or event Anyone can request and lead … Importantly, any team member and request and lead a debrief. … Larsen, anesthesiologist Allison, L&D nurse Hospital AIM Team Leads SPPC-II SCRIPT The team lead,

244. Situation Monitoring: Obstetric Hemorrhage (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_4-situation-monitoring-speaker-notes.pdf
     July 01, 2023 - Rules • Host the debrief as soon as possible following a case or event o Anyone can request and lead … Importantly, any team member and request and lead a debrief. … Larsen, anesthesiologist Allison, L&D nurse SCRIPT The team lead, Dr.

245. Empowering Women and Providers for Improved Care of Urinary Incontinence: EMPOWER Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/urinary/evidencenow_empower.pdf
     January 01, 2024 - Lead organization University Hospitals Cleveland Medical Center (UH Urology Institute, UH Primary Care … Semi-structured interviews are also conducted with the lead provider and project manager at up to 45

246. Guide for Developing a Community-Based Patient Safety Advisory Council (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/advisorycouncil/advisorycouncil.pdf
     April 01, 2008 - AHRQ is the lead Federal agency charged with supporting research designed to improve the equality of … Project Lead The project lead is the coach of the team. … Key characteristics for a project lead include: • A leadership position in the organization. … Project lead roles and responsibilities include: • Developing project goals and objectives. … Staff leads may also represent a discipline or profession, e.g., nurse lead or physician lead.

247. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - Discussion: The models provide contextual maps of the errors and behaviors that lead to medication … between human errors, cultural or behavioral norms, systems, and equipment failures that together may lead … to a manageable size, while addressing the danger that process and procedural variations that may lead … The models provide contextual maps of the errors and behaviors that lead to system failures so that … are not generally reported in the literature, nor are there any descriptions of the behaviors that lead

248. Webinar Agenda - Progress Update: The National Action Alliance for Patient and Workforce Safety—What, Why and How? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/progress-update-2024-agenda.pdf
     January 01, 2024 - Measurement and Value-Based Incentives Group, Centers for Medicare and Medicaid Services • Amanda Carnes, Lead

249. Team Structure and Assembly - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_2-team-structure.pptx
     July 01, 2023 - Therefore, as a Hospital AIM Team Lead you’ll want to understand all perceived losses and make it clear

250. Team Structure and Assembly - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_2-team-structure.pptx
     July 01, 2023 - Therefore, as a Hospital AIM Team Lead you’ll want to understand all perceived losses and make it clear

251. Mutual Support: Severe Hypertension (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
     July 01, 2023 - She reasons that because dangerously elevated blood pressure can lead to stroke or seizures she needs

252. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_6-coaching.pptx
     July 01, 2023 - Unmet expectations often lead to finger pointing, denial of personal responsibility, and other dysfunctional … Unmet expectations often lead to finger pointing, denial of personal responsibility, and other dysfunctional

253. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_6-coaching.pptx
     July 01, 2023 - Unmet expectations often lead to finger pointing, denial of personal responsibility, and other dysfunctional … Unmet expectations often lead to finger pointing, denial of personal responsibility, and other dysfunctional

254. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
     January 01, 2024 - These adverse events, which may lead to hospital readmissions, represent an ongoing threat to patient … often are unaware of test results that return after a patient leaves the hospital—a problem which could lead

255. Geographic Variation in Inpatient Stays for Five Leading Mental Disorders, 2016-2018 | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/hcup/mental-disorders.html
     May 01, 2023 - Geographic Variation in Inpatient Stays for Five Leading Mental Disorders, 2016-2018 This visualization presents rates of hospitalization per 100,000 population for mental disorders during the 3-year period 2016-2018, comparing national, State, and substate areas. Based on an analysis of data from AHRQ's Health…

256. Medical Home Transformation in Pediatric Primary Care – What Drives Change? | Agency for Healthcare Research and Quality
     www.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.

257. The Challenge and Potential for Assuring Quality Health Care for the 21st Century | Agency for Healthcare Research and Quality
     www.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

258. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - Forgetting to put in a stop date may lead to a default stop date of 2 weeks or 30 days, far longer than … time it takes to correct these errors, which involves contacting the facility or the prescriber, may lead … to delays in starting or stopping the antibiotic, and can lead to adverse consequences for the resident … Stasis dermatitis, a condition which occurs because of inadequate function of the venous system, can lead … This patient had a recent cardiac event, which can lead to lower extremity swelling.

259. Implementing the SPPC‐II Teamwork Toolkit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_7-implementation-speaker-notes.pdf
     July 01, 2023 - Determine if refresher training is required • Create training timelines Reference Document: AIM Team Lead … o Frontline staff (step 5) o Limit to 15 frontline staff per Hospital AIM Team Lead in attendance … 15 SCRIPT Schedule regular facilitation sessions (conducted by you, the Hospital AIM Team Lead) … Hospital AIM Team Leads SPPC‐II Step 7: Finalize Your Implementation Plan Step Lead Completion … Along with doing the following steps, you need to know who will lead them, in whole or in part.

260. Preventing CAUTI in the ICU Setting Facilitator’s Guide Transcript | Agency for Healthcare Research and Quality
     www.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.