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  1. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-facilitator-guide.docx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care Learn About the Comprehensive Unit-Based Safety Program for Perinatal … Safety Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety SAY: This module … Slide 5 SAY: In addition to this Learn About CUSP module, the first program pillar includes the … following modules: Assemble the Team/Engage Leadership Understand the Science of Safety Sensemaking and Learn … Slide 30 AHRQ Publication No. 17-0003-1-EF May 2017 AHRQ Safety Program for Perinatal Care Learn
  2. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
    December 01, 2017 - Learn From Defects Tool AHRQ Safety Program for Surgery Learn From Defects Tool – Perioperative Setting … Too few perioperative teams take the opportunity to learn how the defect happened at a systems level, … It shares a based-on-real-life story about a surgical safety team using the Learn From Defects tool to … AHRQ Safety Program for Surgery Learn From Defects—Perioperative 2 II. … Too few perioperative teams take the opportunity to learn how the defect happened at a systems level,
  3. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care Sensemaking and Learn From Defects for Perinatal Safety Sensemaking … and Learn From Defects for Perinatal Safety SAY: The Sensemaking and Learn From Defects module of … Slide 2 SAY: Some of the tools that will help CUSP teams identify and learn from defects include— … The Learn From Defects Form, which provides a standardized means to assess where defects occur and to … Sensemaking is a way for a L&D unit to learn from and prevent mistakes.
  4. ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/learn/index.html
    July 01, 2018 - Healthcare-Associated Infections Program About the CUSP Method Modules Learn … the CUSP Method Project Summary How to Use CUSP Content Calls Modules Learn … about CUSP The Learn about CUSP module of the CUSP Toolkit offers an outline and brief history … Page last reviewed July 2018 Page originally created January 2013 Internet Citation: Learn … https://www.ahrq.gov/hai/cusp/modules/learn/index.html   Back to Top
  5. ce.effectivehealthcare.ahrq.gov/hai/cusp/toolkit/learn-defects.html
    December 01, 2012 - Healthcare-Associated Infections Program About the CUSP Method Modules Learn … the CUSP Method Project Summary How to Use CUSP Content Calls Modules Learn … Defects Tool CUSP Toolkit Health care organizations can increase the extent to which they learn … Problem statement: Health care organizations can increase the extent to which they learn from defects … https://www.ahrq.gov/hai/cusp/toolkit/learn-defects.html   Back to Top
  6. ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/learn/sl-cusp.html
    December 01, 2012 - About CUSP CUSP Toolkit The Learn about CUSP module of the CUSP Toolkit offers an outline … Toolkit Modules Learn About CUSP. Assemble the Team. Engage the Senior Executive. … Provide opportunities for staff to learn and practice using teamwork and communication tools. … Note: This module combines the CUSP steps Identify Defects and Learn from Defects . … Learn how Just Culture principles can augment CUSP. Review key steps of the CUSP Toolkit .
  7. ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/learn/fac-cusp.html
    December 01, 2012 - About CUSP Learn About CUSP, Facilitator Notes … Toolkit Modules   Learn About CUSP. Assemble the Team. Engage the Senior Executive. … Say: The CUSP Toolkit's modules are the following: Learn About CUSP. Assemble the Team. … Note: This module combines the CUSP steps Identify Defects and Learn from Defects . … Learn how Just Culture principles can augment CUSP. Review key steps of the CUSP Toolkit.
  8. ce.effectivehealthcare.ahrq.gov/talkingquality/plan/your-audience/learn-about.html
    July 01, 2011 - Assess Your Reporting Project Resources About TalkingQuality How To Learn … reviewed July 2011 Page originally created February 2015 Internet Citation: How To Learn … https://www.ahrq.gov/talkingquality/plan/your-audience/learn-about.html  
  9. ce.effectivehealthcare.ahrq.gov/hai/cusp/videos/04e-learn-defects/index.html
    June 01, 2018 - Healthcare-Associated Infections Program About the CUSP Method Videos Learn … Reports Videos Decolonization – Universal and Targeted Tools LearnLearn From Defects [2 min. 58 sec.] … Page last reviewed June 2018 Page originally created February 2013 Internet Citation: Learn … https://www.ahrq.gov/hai/cusp/videos/04e-learn-defects/index.html   Back
  10. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp.pptx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care: Learn About the Comprehensive Unit-based Safety Program AHRQ … Safety Program for Perinatal Care Learn About the Comprehensive Unit-based Safety Program for Perinatal … Safety AHRQ Publication No. 17-0003-1-EF May 2017 1 CUSP and Perinatal Safety 2 Learn About CUSP … 4 Learn About CUSP AHRQ Safety Program for Perinatal Care   4 Safety Program for Perinatal Care 5 … Learn About CUSP AHRQ Safety Program for Perinatal Care SPPC CUSP Modules Learn About CUSP Assemble
  11. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
    December 01, 2017 - PowerPoint Presentation: Learn From Defects for Sustainability Sustainability: Learning From Defects … Dig into the literature to learn how others have faced similar defects. … Learn from defects on a regular basis. … A practical tool to learn from defects in patient care. … Learn From Defects ‹#› AHRQ Safety Program for Surgery – Sustainability 25
  12. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/lhs/how_learning_health_systems_learn.pdf
    November 06, 2019 - How Learning Health Systems Learn: Lessons from the Field Evidence generators Evidence curators … curators Evidence adopters Evidence disseminators Evidence managers How Learning Health Systems Learn … : Lessons from the Field e 1 How Learning Health Systems Learn: Lessons from the Field A … AHRQ conducted site visits at a few leading organizations to learn about the steps they have taken to
  13. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
    December 01, 2017 - PowerPoint Presentation: Learn From Defects Through Sensemaking Learning From Defects Through Sensemaking … 3 Standardize Care Create Independent Checks Learn From Defects Problem-Solving Hierarchy … Asking people to read, learn, and apply the learning enables people to form memories of the process. … In the first month, you learn that only 15 out of 30 patients had the proper body temperature. … A practical tool to learn from defects in patient care.
  14. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdf
    May 01, 2017 - Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety AHRQ Safety Program for … Perinatal Care Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety AHRQ … Slide 5 Learn About Comprehensive Unit-Based Safety Programs for Perinatal Safety AHRQ Safety … Program for Perinatal Care Learn About CUSP 3 SAY: In addition to this Learn About CUSP module, … Program for Perinatal Care Learn About CUSP 8 How were these at-risk behaviors handled?
  15. ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
    February 01, 2017 - Patients: Facilitator Guide AHRQ Safety Program for Mechanically Ventilated Patients Slide 1: Learn … This module focuses specifically on the fourth step, which is to learn from defects. … Asking people to read, learn, and apply the learning enables people to form memories of the process. … last reviewed February 2017 Page originally created February 2017 Internet Citation: Learn … https://www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html  
  16. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
    May 01, 2017 - and Learn From Defects for Perinatal Safety AHRQ Publication No. 17-0003-5-EF May 2017 SAY: The … Care Sensemaking & Learn From Defects 2 • The Learn From Defects Form, which provides a standardized … Sensemaking is a way for a L&D unit to learn from and prevent mistakes. … Care Sensemaking & Learn From Defects 12 • Step 2. … & Learn From Defects 14 SAY: After working through the Sensemaking and Learn From Defects processes
  17. ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.html
    March 01, 2017 - Infections Program Tools Reduce CAUTI in LTC Facilities Toolkit Sections Learn … Ambulatory Settings Telemedicine Universal ICU Decolonization Protocol Learn … Page last reviewed March 2017 Page originally created March 2017 Internet Citation: Learn
  18. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
    May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects … AHRQ Safety Program for Perinatal Care Sensemaking and Learn From Defects for Perinatal Safety AHRQ … 0003-5-EF May 2017 1 Learning Objectives 2 AHRQ Safety Program for Perinatal Care Sensemaking & Learn … Model 4 AHRQ Safety Program for Perinatal Care Sensemaking & Learn from Defects Identify Defects … from Defects 19 Summary: Sensemaking and Learn From Defects Sensemaking and Learn From Defects share
  19. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects_facnotes.docx
    December 01, 2017 - Accessible Facilitator Guide: Learn From Defects for Sustainability Slide Title and Commentary Slide … Dig into the literature to learn how others have faced similar defects. … Keep in mind the principles of safe design: · Standardize care · Create independent checks · Learn from … That momentum will help your team learn from more complex defects and garner resources to address them … Learn from defects on a regular basis.
  20. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - The Learn From Defects Form, which provides a standardized means to assess where defects occur and to … Sensemaking is a way for a L&D unit to learn from and prevent mistakes. … Further guidance to complete this exercise can be found using the CUSP Learn From Defects form. … Create a one-page summary answering the four Learn From Defects questions. … Engage staff in face-to-face conversations to provide opportunities to learn from defects.

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