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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.pdf
May 01, 2017 - Learning
from defects includes using both informal and
formal processes that seek to understand
rather … The L&D unit can decide its approach to
learning from defects based on seriousness of
event, expertise … adverse outcomes using formal methods of
analysis reviewed in prior presentations can
be used for learning … informal and formal
debriefings and analysis with staff to achieve
transparency and organizational learning
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-4/share-tool4.pdf
April 01, 2014 - Review of adult learning and literacy
(vol. 7) (pp 175–204).
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/baker_crc_screening.pdf
January 01, 2014 - Improving Rates of Repeat Colorectal Cancer Screening in Community Health Centers
Research Centers for Excellence
in Clinical Preventive Services
Working to get the right services, to the right people, at the right time
Improving Rates of Repeat Colorectal Cancer
Screeni…
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule2.pptx
February 09, 2006 - Learning about properly forming a team is essential to creating an effective teamwork environment. … As you work through this material, I recognize that not only are you learning the material, you're learning … They should strive to create a learning culture, where there's trust and transparency, where it's safe … To complete this module and receive accreditation, you must return to the TeamSTEPPS Learning Management
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfepc-fullguide-appc-final508.pdf
April 13, 2018 - Teach-Back Interactive Module
The Teach-back interactive module is a self-directed, self-paced learning … Practice
The teach-back strategy includes a training guide, slides, role play scenarios, an interactive
learning
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-august2013.pptx
January 01, 2013 - Improvement from
2007 to 2009 Improvement from
2009 to 2010 Improvement from
2007 to 2011
Organizational Learning … Transitions 8.0%
Hospital Management Support.. 5.8%
Nonpunitive Response to Error 5.7%
Organizational Learning
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healthcare411.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 learning … Learning Objectives
Slide 3. Electronic Fetal Monitoring
Slide 4.
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healthcare411.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
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healthcare411.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
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healthcare411.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.
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healthcare411.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
-
healthcare411.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…
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healthcare411.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
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healthcare411.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
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healthcare411.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 …
-
healthcare411.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
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
November 01, 2012 - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/Downloads/wPOA-Fact-Sheet.pdf … _13_FINAL.pdf
http://www.nothingleftbehind.org/
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
-
healthcare411.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
-
healthcare411.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
-
healthcare411.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