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1821. Patient Safety Executive Walkarounds (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Graham.pdf
      April 01, 2004 - several similar-looking sets of medicine vials were stored in one narrow drawer, posing a risk for a medication … error, the drawer system was replaced and look-alike drugs were clearly separated.

1822. The Challenge and Potential for Assuring Quality Health Care for the 21st Century | Agency for Healthcare Research and Quality
      ce.effectivehealthcare.ahrq.gov/patient-safety/quality-measures/21st-century/index.html
      June 01, 2018 - Medication Errors .

1823. Situation Monitoring: Severe Hypertension (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring-speaker-notes.pdf
      July 01, 2023 - Situation Monitoring: Severe Hypertension Hospital AIM Team Leads SPPC‐II Situation Monitoring Severe Hypertension Module 4 of 8 SPPC‐II Toolkit SCRIPT Welcome to Module 4 of the SPPC‐II Teamwork Toolkit. In this module, we will talk about situation monitoring: what it is, how to do it, and what tools a…

1824. Chapter-7 - Harm Due to Anticoagulants (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/anticoagulants-1.pdf
      March 01, 2020 - Effect of a pharmacist intervention on clinically important medication errors after hospital discharge

1825. Strategies to Improve Communication Between Pharmacy Staff and Patients: A Training Program for Pharmacy Staff (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pharmhealthlit/pharmlit/pharmtrain.pdf
      January 01, 2010 - Strategies to Improve Communication Between Pharmacy Staff and Patients: A Training Program for Pharmacy Staff Strategies to Improve Communication Between Pharmacy Staff and Patients: A Training Program for Pharmacy Staff Curriculum Guide Prepared for…

1826. Challenges to Real-Time Decision Support in Health Care (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
      January 01, 2007 - Challenges to Real-Time Decision Support in Health Care Challenges to Real-Time Decision Support in Health Care Mark Fitzgerald, MB, BS, FACEM; Nathan Farrow, RN, BN (Hons) Adv Nur (Critical Care); Pamela Scicluna, BSc; Angela Murray, RN; Yan Xiao, PhD; Colin F. Mackenzie, MBChB, FRCA, FCCM Abstract This …

1827. Facilitator-Notes (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module1/facilitator-notes.docx
      March 01, 2017 - tools are used in combination with clinical or operational efforts to minimize harms such as falls, medication … errors, and healthcare-associated infections, such as catheter-associated urinary tract infections.

1828. TeamSTEPPS Learning Benchmarks (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
      May 31, 2023 - TeamSTEPPS Learning Benchmarks TeamSTEPPS Learning Benchmarks Instructions: These questions focus on medical teamwork and communication and their effect on quality and safety in patient care. For each of the following questions, please circle the letter next to the one best answer. 1. A nurse is called t…

1829. Shadowing Another Professional Tool | Agency for Healthcare Research and Quality
      ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/professional-tool.html
      July 01, 2023 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

1830. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
      March 27, 2008 - The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures 1 The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures Lawrence L. Faltz, MD, FACP; John N. Morley, MD, FACP…

1831. Scenario 1 (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/learnbench.pdf
      February 28, 2014 - Scenario 1 TeamSTEPPS Learning Benchmarks INSTRUCTIONS: These questions focus on medical teamwork and communication and their effect on quality and safety in patient care. For each of the following questions, please circle the letter next to the one best answer. 1. A nurse is called to the phone to recei…

1832. TeamSTEPPS Specialty Scenarios: Ancillary Services (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/ancillary.pdf
      March 19, 2014 - question, she appropriately raises the question again, which results in the correction of a potential medication … error.

1833. PowerPoint Presentation
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
      January 01, 2014 - PowerPoint Presentation Communication and Optimal Resolution (CANDOR): Grand Rounds Presentation Presenter: Timothy B. McDonald, MD, JD This presentation will introduce you to Communication and Optimal Resolution, or the CANDOR process. Some organizations struggle to improve the way they and their care teams respond…

1834. Selected Best Practices and Suggestions for Improvement (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
      May 20, 2016 - associated with drug reaction ∗ Death associated with adverse drug reaction ∗ Death associated with medication … error ∗ Death associated with medical device ∗ Healthcare-associated infection ∗ Fall during hospitalization

1835. What Exactly Is Patient Safety? (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
      July 02, 2008 - subsequent demonstration with Bates and colleagues6 of the utility of systems analysis in understanding medication … error later that year, provided that new type of thinking.

1836. Pediatric Health Care Quality Measures: Considerations for Pharmacotherapy (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/LomotanDougherty2013.pdf
      April 01, 2013 - Tenfold medication errors: 5 years’ cators for children with sickle cell disease.

1837. Mod01-Grand-Rounds-Slides (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
      April 01, 2016 - Say: This presentation will introduce you to Communication and Optimal Resolution, or the CANDOR process. Some organizations struggle to improve the way they and their care teams respond to medical harm. The CANDOR process aims to change that. Slide 1 Say: To get started, let’s watch this video. Video: Do Less…

1838. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
      April 18, 2004 - Seamless Care: Safe Patient Transitions from Hospital to Home 79 Seamless Care: Safe Patient Transitions from Hospital to Home Andrea M. Spehar, Robert R. Campbell, Carron Cherrie, Polly Palacios, Donna Scott, Jacquelyn L. Baker, Brad Bjornstad, Jay Wolfson Abstract Background: “Seamless care” is a smooth a…

1839. Looking for Trouble in All the Right Places: The Legal Implications Associated with “Electronic Signatures” and High-risk Clinical Situations (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Escobar.pdf
      February 01, 2005 - Medication errors are important, but they are not the only kind of error in medicine.

1840. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
      May 19, 2003 - Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis 323 Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis Kathleen A. Harder, John R. Bloomfield, Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush, Jamie S. Sinclair,…