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  1. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
    May 01, 2017 - multidisciplinary review of actual EFM strips from past patients for the purposes of teaching and learning … Another option is a regular forum with a multidisciplinary team that uses formal tools or analysis for learning … analysis is shared with staff, and with whom, to achieve transparency and enhance organizational learningLearning Objectives Slide 3. Electronic Fetal Monitoring Slide 4.
  2. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsacknowledgments.pdf
    October 30, 2009 - developing an evidence-based framework, providing validated measurement tools, incorporating adult-learning
  3. Teamcheckup (doc file)

    cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/teamcheckup.doc
    August 07, 2012 - improvement skills on our team. 7 We perform a unit analysis for each incident using the Learning
  4. cahps.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-II.pdf
    January 01, 2023 - Organizational Learning – Continuous Improvement 94% 93% 91% 91% 90% 2. … Organizational Learning – Continuous Improvement 93% 92% 90% 91% 93% 92% 93% 89% 91% 2. … Organizational Learning – Continuous Improvement 90% 98% 88% 99% 97% 88% 90% 88% 93% 2. … Organizational Learning – Continuous Improvement 94% 91% 90% 94% 2. … (Item C2) 93% 85% 80% 90% Learning, rather than blame, is emphasized when mistakes are made.
  5. cahps.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule4.pptx
    March 10, 2006 - So these really are an excellent learning opportunity for the team members. … where people can fairly and honestly talk about mistakes that might have been done, and see this as a learning … effectively resolve the conflict, it can assure that the patient gets good care, but it also provides learning … And this provides, again, an opportunity for learning and for discussion about what's most effective, … To complete this module and receive accreditation, you must return to the TeamSTEPPS Learning Management
  6. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/persell_cvd_disparities.pdf
    September 18, 2014 - Reducing Disparities in the Primary Prevention of Cardiovascular Disease Research Centers for Excellence in Clinical Preventive Services Working to get the right services, to the right people, at the right time Reducing Disparities in the Primary Prevention of Cardiovascular Disease…
  7. Safemed Facguide (doc file)

    cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.docx
    May 01, 2017 - The key safety elements related to learning from defects for oxytocin administration include— Debriefing … improvement from informal and formal analysis with staff to achieve transparency and organizational learning … The key safety elements of learning from defects are the same as for oxytocin: Debriefing near misses … the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning
  8. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/ancillary.pdf
    March 19, 2014 - this case, a transfer of knowledge has occurred through the processes of situational teaching and learning … A team member, seeing an opportunity for learning, calls the RT team together and discusses the importance … This scenario shows that even those activities that do not result in bad outcomes can be turned into learning … In this case, a debrief using mutual support can provide constructive feedback and result in a learning … Instructor Comments  This scenario shows the lessons learned from changes to facilitate teamwork and learning
  9. cahps.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/evidencenow-story.pdf
    September 01, 2021 - EvidenceNOW: A Model for Heart Health and Beyond B S A B LDL C S A B HDL LDL C S A B HDL LDL C S A B LDL C S B S A B HDL LDL C S A BHDL LDL C S A B HDL LDL C S A B HDL LDL C S NATIONAL CENTER FOR EXCELLENCE IN PRIMARY CARE RESEARCH EvidenceNOW: A Model for Heart Health and …
  10. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - death. 44% of adverse events were preventable. 5 Following Harm: Not Always Transparent, Not Always Learning … Barriers Fears Litigation Data Bank Shame, blame Reputation Lack of skills Lack of process Benefits Learning … Benefits from an open and transparent culture include: Organizational learning that leads to improvements … of CANDOR Module 1 27 The culture of the CANDOR process provides the opportunity for continuous learning … Organizational learning and sustainment—The organization takes what they have learned from the event
  11. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
    January 01, 2012 - for Medicare & Medicaid Services; October 2012. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN … national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN … /MLNProducts/Downloads/wPOA-Fact-Sheet.pdf https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN
  12. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back-role-play-final508.pdf
    April 05, 2018 - Using the discussion prompts (page 3), engage the training group in a learning discussion on what went … Using the discussion prompts (page 3), engage the training group in a learning discussion on what went … Using the discussion prompts (page 3), engage the training group in a learning discussion on what went
  13. cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-roleplay-final508.pdf
    April 03, 2018 - Using the discussion prompts (page 3), engage the training group in a learning discussion on what went … Using the discussion prompts (page 3), engage the training group in a learning discussion on what went … Using the discussion prompts (page 3), engage the training group in a learning discussion on what went

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