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pbrn.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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pbrn.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/index.html
May 01, 2016 - Records
Vendors With On-Time Experience
Case Studies
More Information
If you are interested in learning
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pbrn.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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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/handouts/readiness.pdf
August 01, 2005 - identified for the
effort to devote sufficient time to the project, including time spent on their own learning … staff in your practice/the practice you support have enough flex time during the
workday to commit to learning … To prevent disruptions and scheduling issues and to
maximize learning, the practice will need to design … Enhancing continuous learning: diagnostic findings from multiple
companies.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/sbar-inpatient-guide.pdf
August 31, 2023 - TeamSTEPPS Video Debrief Guide: SBAR on Inpatient Medical Unit
TeamSTEPPS Video Debrief Guide: SBAR on Inpatient
Medical Unit
Video Objective
To demonstrate each step of SBAR and emphasize the importance of standard communication and use
of the tool.
TeamSTEPPS Tool or Concept
SBAR.
Brief Video Descriptio…
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pbrn.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/evidencenow-story.pdf
September 01, 2021 - EvidenceNOW: A Model for Heart Health and Beyond
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NATIONAL CENTER
FOR EXCELLENCE IN
PRIMARY CARE RESEARCH
EvidenceNOW: A Model for Heart Health and …
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medoffice-resourcelist.pdf
April 01, 2023 - Organizational Learning ............................................................................ … It is
primarily targeted to individual licensed clinicians for learning and improvement purposes. … Organizational Learning
1. Root Cause Analysis
a. … Developing a Reporting Culture: Learning From Close Calls and Hazardous Conditions
3. … Organizational Learning
1. Root Cause Analysis
2.
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pbrn.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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pbrn.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
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pbrn.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
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pbrn.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
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pbrn.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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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule8.pptx
March 28, 2006 - Share the information you know
Encourage teamwork and collaboration
Encourage personal reflection and learning … Additionally, encourage personal reflection and learning. … This learning step and reflective piece is a step that's often missed or under-emphasized. … short-term wins and really recognizing the folks for those efforts, recognizing that it really is a learning … This will include making adjustments to the change vision and strategy to reflect the new learning and
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/cus-facilitator-guide-maternal-equity.pdf
August 30, 2023 - TeamSTEPPS Video Debrief Guide: CUS-Maternal Health
TeamSTEPPS Video Debrief Guide: CUS for Diversity, Equity,
and Inclusion in Maternal Health
Video Objective
To demonstrate an example of how to speak up, using a TeamSTEPPS technique.
TeamSTEPPS Tool or Concept
CUS: I am Concerned; I am Uncomfortable; This is …
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/video/cus-sbar-rural-clinic-guide.pdf
August 30, 2023 - TeamSTEPPS Video Debrief Guide: CUS and SBAR in Rural Community Clinic
TeamSTEPPS Video Debrief Guide: CUS and SBAR in Rural
Community Clinic
Video Objective
To demonstrate how CUS is used to ensure patient safety and showcase the SBAR communication
technique.
TeamSTEPPS Tool or Concept
CUS, SBAR.
Brief V…
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation.docx
August 31, 2017 - Learning Methodology Checklist
· Large group discussion
· PowerPoint slide presentation
Additional … First, adult learning theory suggests that adults learn best through methods that build on their own … Slide 32
SAY: Because individuals have different learning styles and are at different levels of practice
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/pharmsops-composites.pdf
June 19, 2018 - Organizational Learning—Continuous Improvement
(Strongly Disagree, Disagree, Neither Agree nor Disagree … Organizational Learning—Continuous Improvement
11.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule7.pptx
November 02, 2018 - TeamSTEPPS 2.0 Module 7: Summary: Pulling It All Together
Module 7: Pulling It All Together
Online Master Trainer Course
Welcome to the
Welcome to module seven of the TeamSTEPPS 2.0 online master trainer course, pulling it all together. This is Dr. Brigetta Craft, and I'll be guiding you through this module.…
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module1.pptx
March 01, 2010 - ‹#›
During this course, the Participant Workbook will be your primary tool for completing all the learning
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.docx
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 … debriefings or formal analysis is shared with staff to achieve transparency and enhance organizational learning