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61. A medical error leads to tragedy: how do we inform the patient? | PSNet
    psnet.ahrq.gov/issue/medical-error-leads-tragedy-how-do-we-inform-patient
    April 08, 2018 - Commentary A medical error leads to tragedy: how do we inform the patient? … A medical error leads to tragedy: how do we inform the patient? … A medical error leads to tragedy: how do we inform the patient?

62. Parkland knee surgery done by doctor in training leads to amputation, questions. | PSNet
    psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions
    August 11, 2010 - Newspaper/Magazine Article Parkland knee surgery done by doctor in training leads … Citation Text: Parkland knee surgery done by doctor in training leads to amputation, questions. … Cite Citation Citation Text: Parkland knee surgery done by doctor in training leads

63. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet
    psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. … Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. … Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads

64. Team Structure and Assembly (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_2-team-structure-speaker-notes.pdf
    July 01, 2023 - Team Structure and Assembly Hospital AIM Team Leads SPPC‐II Team Structure and Assembly Module … This module will introduce concepts of team structure and assembly. 1 Hospital AIM Team Leads … in the implementation of the SPPC‐II Teamwork Toolkit at your facility. 2 Hospital AIM Team Leads … The charge nurse, an anesthesiologist, and a unit clerk. 12 Hospital AIM Team Leads SPPC‐II … As Hospital AIM Team Leads, it is part of your role to help them see the value in these tools.

65. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43863/psn-pdf
    July 16, 2015 - Learning through simulated independent practice leads to better future performance in a simulated crisis … Learning through simulated independent practice leads to better future performance in a simulated crisis … https://psnet.ahrq.gov/issue/learning-through-simulated-independent-practice-leads-better-future- performance-simulated … https://psnet.ahrq.gov/issue/learning-through-simulated-independent-practice-leads-better-future-performance-simulated … https://psnet.ahrq.gov/issue/learning-through-simulated-independent-practice-leads-better-future-performance-simulated

66. 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 - Mutual Support: Severe Hypertension Hospital AIM Team Leads SPPC‐II Mutual Support Severe Hypertension … different facets of mutual support and strategies for supporting each. 1 Hospital AIM Team Leads … monitoring, which keeps teammates aware of team member and patient needs. 2 Hospital AIM Team Leads … can say “sure, I have 5 minutes” to set a parameter before you begin. 3 Hospital AIM Team Leads … This time, it works, and Melanie agrees to stay and help. 17 Hospital AIM Team Leads SPPC‐II

67. Mutual Support: Obstetric Hemorrhage (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support-speaker-notes.pdf
    July 01, 2023 - SPPC‐II Toolkit                                                               Hospital AIM Team Leads … Managing conflict Hospital AIM Team Leads SPPC‐II 2                                   … members protect each other from work overload situations o You can set limits Hospital AIM Team Leads … tach Do post Hospital AIM Team Leads SPPC‐II Challenge #1! Tanya calls Dr. … Hospital AIM Team 28 Leads SPPC‐II SCRIPT Building from the obstetric hemorrhage master case

68. Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. | PSNet
    psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-overdose
    June 03, 2020 - Magazine Article Incorrect use of smart infusion pump in the operating room (OR) leads … Citation Text: Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose … Citation Citation Text: Incorrect use of smart infusion pump in the operating room (OR) leads … December 7, 2022 WebM&M Cases Saline Flush Leads to Acute

69. Roll-Out Diagram Generic (pdf file)
    psnet.ahrq.gov/sites/default/files/2021-09/Roll-out%20diagram%20generic.pdf
    January 01, 2021 - program as part of a psychological resilience intervention Can stand alone* Specific nursing unit leads … request program roll-out for unit/department Resilience program lead meets with dept/unit leads … to assess needs and explain program Program leads facilitate “all hands” launch meeting with … of Battle Buddies Distribute Battle Buddy Pairings and Pocket Card to dept/unit members Key leads

70. Communication: Severe Hypertension (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3-communication-speaker-notes.pdf
    July 01, 2023 - Communication: Severe Hypertension Hospital AIM Team Leads SPPC‐II Communication Severe Hypertension … We’ll begin with a brief conceptual overview. 1 Hospital AIM Team Leads SPPC‐II Communication … 12 Hospital AIM Team Leads SPPC‐II When To Use a Call‐Out • Whenever information needs to … 17 Hospital AIM Team Leads SPPC‐II Check‐Back It’s been 15 minutes, and the patient’s BP … Then notice the confirmation during the check‐back. 27 Hospital AIM Team Leads SPPC‐II

71. Lessons on How To Improve Future National Collaboratives | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/cusp/clabsi-final/clabsifinal5.html
    January 01, 2013 - Teams reported to the State leads that the monthly data collection was too frequent and found the tool … All State leads further reported that senior leader engagement was very important to their successful … Some State leads used small incentives like inexpensive food gift cards to encourage struggling teams … Strong State Hospital Association (SHA) Engagement to Increase Unit Accountability State leads who … After this point State leads led the coaching calls on their own.

72. 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 - No. 23-0046 July 2023 Hospital AIM Team Leads SPPC-II SCRIPT Welcome to Module 4 of the SPPC-II Teamwork … 3 Hospital AIM Team Leads SPPC-II SCRIPT Don’t ruin this exercise for others if you’re already familiar … Always check-back to verify information (Module 3). 4 Hospital AIM Team Leads SPPC-II SCRIPT Now that … Huddles are held ad hoc at any time during care. 5 Hospital AIM Team Leads SPPC-II SCRIPT You have … 26 Hospital AIM Team Leads SPPC-II SCRIPT Click the video to see an example of a debrief. 

73. AHRQ Impact Case Studies Criteria | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/news/newsroom/case-studies/criteria.html
    December 01, 2019 - Impact Case Studies are developed by AHRQ's Office of Communications (OC) based on leads that are provided … Viable leads follow the general development process outlined below. … Criteria Development of an Impact Case Study starts by collecting leads. … Viable leads must meet the following criteria: The user (person or entity that uses AHRQ’s material

74. AHRQ Impact Case Studies Criteria | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/news/newsroom/case-studies/criteria.html
    December 01, 2019 - Impact Case Studies are developed by AHRQ's Office of Communications (OC) based on leads that are provided … Viable leads follow the general development process outlined below. … Criteria Development of an Impact Case Study starts by collecting leads. … Viable leads must meet the following criteria: The user (person or entity that uses AHRQ’s material

75. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/40641/psn-pdf
    July 27, 2011 - Error in body weight estimation leads to inadequate parenteral anticoagulation. … Error in body weight estimation leads to inadequate parenteral anticoagulation. … https://psnet.ahrq.gov/issue/error-body-weight-estimation-leads-inadequate-parenteral-anticoagulation … https://psnet.ahrq.gov/issue/error-body-weight-estimation-leads-inadequate-parenteral-anticoagulation

76. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/36416/psn-pdf
    December 22, 2010 - A medical error leads to tragedy: how do we inform the patient? December 22, 2010 Baumrucker SJ. … A medical error leads to tragedy: how do we inform the patient? … https://psnet.ahrq.gov/issue/medical-error-leads-tragedy-how-do-we-inform-patient This roundtable discussion … https://psnet.ahrq.gov/issue/medical-error-leads-tragedy-how-do-we-inform-patient

77. Program Implementation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/clabsi-final/clabsifinal2.html
    January 01, 2013 - Return to Contents Education Program Teleconferences and In-person Meetings State leads and their … began presenting on monthly supplemental calls after several months into the project and once State leads … State leads and the NPT received positive feedback from unit teams on this peer-to-peer teaching. … State leads were required to host at least two in-person meetings throughout the course of their two-year … Given the limited number of faculty advisors and the need to encourage State leads to learn how to coach

78. Figure 1.2. Framework for a System Approach to Tracking and Increasing Screening for Population Health Improvement Regarding Colorectal Cancer (SATIS-PHI/CRC) (Text Description) | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreenfigtxt1-2.html
    April 01, 2018 - Step 1 leads directly to Step 2. … Step 1 also leads directly to Step 3.

79. Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/perinatal-care-2/index.html
    July 01, 2023 - Tier 2: AIM Team Leads The SPPC-II Teamwork Toolkit recognizes that individuals responsible for making … These individuals, termed “AIM Team Leads,” were identified by the State AIM leadership in their State … As leaders who “champion” these initiatives, AIM Team Leads may benefit from more conceptual understanding … , emodules for education of frontline clinicians, PowerPoint slide sets for AIM Team Leads, and a guide … Frontline clinicians and AIM Team Leads can review these individually, or they can be presented as part

80. Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/index.html
    July 01, 2023 - Tier 2: AIM Team Leads The SPPC-II Teamwork Toolkit recognizes that individuals responsible for making … These individuals, termed “AIM Team Leads,” were identified by the State AIM leadership in their State … As leaders who “champion” these initiatives, AIM Team Leads may benefit from more conceptual understanding … , emodules for education of frontline clinicians, PowerPoint slide sets for AIM Team Leads, and a guide … Frontline clinicians and AIM Team Leads can review these individually, or they can be presented as part