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pbrn.ahrq.gov/teamstepps/rrs/rrsspecscen.html
October 01, 2014 - The family member alerted the nurse about these concerns. … The nurse assured the family member that she would check on the patient. … An hour later, the family member reminded the nurse, who then assessed the patient. … The nurse checked the patient’s vital signs. … Based on her colleague’s recommendation, the nurse called the RRT via the operator.
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pbrn.ahrq.gov/hai/cusp/toolkit/bckgrnd-qi-team.html
December 01, 2012 - Defects Through Sensemaking
Implement Teamwork and Communication
Apply CUSP
Role of the Nurse … Insert Unit Type> Director
Hospital Patient Safety Officer or Chief Quality Officer
Nurse … Champion
Nurse Educator
Nurse Manager
Nurses on team (list all)
Physicians on team (list all)
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/leputcomesasst.pdf
July 25, 2012 - The receptionist,
Carolyn, knows that one of the nurses, Betty, speaks Spanish. … Through the interpreter, Nurse Arroyo tells the patient, Mr. … Say to the nurse, “Let me check back with you. … Nurse Angelis is preparing to discharge Mr. … Khang, interprets Nurse Angelis’s
instructions. The patient nods. Nurse Angelis states that Mr.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/handouts/knowledge.pdf
December 02, 2015 - Registered Nurse
d. … Nurse Jones is conducting a handoff. … Communication between physicians and nurses
b. … A nurse corrects a misstatement made by the physician, but the physician ignores the correction. … What should the nurse do in this situation?
a.
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pbrn.ahrq.gov/teamstepps/lep/handouts/lepbriefingex.html
December 01, 2012 - I need someone to play the nurse, someone to play the interpreter, and someone to play the patient. … Nurse: Hi, [interpreter name]. I'm nurse [name]. We are going to discharge [patient name] today. … [Interpreter and nurse walk into patient room]
Nurse: Hi, [patient name]. I'm [ nurse name ]. … Interpreter: [ interprets ]
Patient: [ nods ]
Nurse: Next, I'm going to go over your medications … Interpreter: [ interprets ]
Nurse: First, we want you to take aspirin once a day to help keep your
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pbrn.ahrq.gov/hai/cauti-tools/archived-webinars/leveraging-cultural-change-slides.html
December 01, 2017 - Intensivists
Nurse Manager
MD Director
Nurses
Image: Cartoon of a yellow schoolbus with the words … Medical Director
Nurse Manager
Nurses
Intensivists
Others
Slide 14
Three Levels of Organizational … Nurse Med calls back to the ED 20 minutes later and asks for Nurse ED. … The Nurse manager does not “want to make waves” and has not made the nurses accountable for following … What about the nurse manager?
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/medsurg.pdf
March 19, 2014 - Nurse M, who is caring for Mr. … Hospital protocol
requires two nurses to verify that the correct patient is receiving the correct blood … Nurse M decides to hang the blood without the
double check. … Neither the charge nurse nor the patient’s nurse is aware of a plan for
this procedure. … Nurse R, who is assigned to admit the patient, tells the ED nurse
calling with the report that she “
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/learnbench.pdf
February 28, 2014 - Go scrub and tell the circulating nurse to “get the ball rolling.”
b. … Tell the nurse to stop undercutting her.
b. … Tell the clinic manager to have a talk with the nurse.
d. … Just let the patients know that the nurse is having a bad day. … The doctor has often been short tempered around
the nurses and techs and doesn’t take suggestions very
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pbrn.ahrq.gov/teamstepps/instructor/scenarios/operroom.html
March 01, 2014 - Helen, the nurse coordinator, identifies an open room for the following day and moves Mr. … The O.R. circulating nurse places a tourniquet on the left thigh. … providers are around the bed, including the ICU attending physician, a consultant pulmonologist, two ICU nurses … one ICU nurse for all medication administration. … Larry is the perioperative team circulating nurse working with Jane as the scrub nurse for a patient
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pbrn.ahrq.gov/teamstepps/instructor/scenarios/ambulatory.html
October 01, 2014 - The nurse is embarrassed but does not speak to the doctor about the situation. … Cindy S., a nurse, is at the bedside inserting an IV. … Lora A. is the nurse at the cart drawing up the meds. … The lunch relief nurse comes on just as the patient leaves for X Ray. … The unit clerk is aware of the plan, but the patient’s nurse is not.
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pbrn.ahrq.gov/hai/tools/ambulatory-surgery/about.html
May 01, 2017 - Participating organizations
American Academy of Orthopaedic Surgeons
American Association of Nurse … Association of periOperative Registered Nurses
International Association of Healthcare Central Service
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pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.html
August 01, 2022 - #1
Charge nurse
Nurse #2
RN
CNA X
Nursing tech
Manager MS
Manager
Pertinent Interview … The charge nurse usually doesn’t take patient assignments; however, the emergency department was on bypass … Nurse #1 and Nurse #2 both said they were speaking to the tech at the same time while she was passing … The CNA referred to both of the patients as "your patient" when providing each nurse with results. … There was an opportunity to ask a clarifying question of the tech and nurses about patient identification
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-II.pdf
January 01, 2023 - incidents were “Always” or “Most of the time”
documented in an incident or occurrence report (98 percent); Nurses … follows:
• Anesthesiologist
• Doctor/Physician (excluding Anesthesiologists) or Surgeon
• Certified Registered … Nurse Anesthetist (CRNA)
• Physician Assistant or Nurse Practitioner
• Management: Medical Director … , Office Manager, Other Manager
• Nurse: Registered Nurse (RN), Licensed Practical Nurse (LPN)/Licensed … In addition, those who worked 17 to 31 hours per
week were primarily nurses, and those who worked more
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pbrn.ahrq.gov/teamstepps/instructor/scenarios/icu.html
March 01, 2014 - Instructor Comments
In this scenario, time, nurses, and information handoffs are scarce. … Neither nurse seeks assistance from her teammates. … Judy, a nurse, is at the bedside inserting an IV. … Nancy is the nurse at the cart drawing up the meds. … Several of the doctors and nurses say they were surprised at the time that the seizure was not being
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pbrn.ahrq.gov/teamstepps/instructor/scenarios/neonatalicu.html
March 01, 2014 - Two hours later, the nurse contacts the resident and again expresses her concern that the baby "just … The resident reassures the nurse and says he thinks the baby is fine. … The nurse asks that the attending physician be called, but the resident refuses. … the room and, without assessing the patient or learning the history, begins calling out orders to the nurses … At 0930, the nurse caring for the infant realizes that the infant is still NPO and on no IVF.
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pbrn.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
December 01, 2017 - Lisa Wolf, and she is with the Emergency Nurses Association. … Is it the nurses? Is it a nurse-driven environment? Is it your physicians? … How does – how do nurses and physicians transmit concern back and forth? … So, you know, is it the nurses? Is it the physicians? Is it a combination? … that nurse say, “You know what?
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pbrn.ahrq.gov/talkingquality/measures/setting/long-term-care/nursing-home/examples.html
April 01, 2019 - Registered Nurses (RNs).
Licensed Vocational Nurses (LVNs) or Licensed Practical Nurses (LPNs).
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pbrn.ahrq.gov/hai/cusp/modules/identify/identify.html
December 01, 2012 - Transfusing nurse didn’t check blood type on hanging unit.
Nurse was busy and distracted. … Recovery
Nurse interrupts transfusion.
Nurse sees that unit is A positive. … Root Causes
Temp nurse unclear about procedure.
Temp nurses need help. … Other nurses on sick-out. … Transfusing nurse busy and distracted.
Both nurses from outside the agency.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsspecscen.pdf
January 11, 2010 - The family member alerted the nurse about these
concerns. … The nurse assured the family member that she would
check on the patient. … An hour later, the family member reminded
the nurse, who then assessed the patient. … The nurse checked the
patient’s vital signs. … Based on her colleague’s
recommendation, the nurse called the RRT via the operator.
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/assemble/assembleteam.docx
August 24, 2012 - This individual will:
· Be a frontline provider—a staff nurse, nurse manager, nurse educator, or physician … For example, the nurse opinion leader can serve as the representative for all unit nurses on the CUSP … of the unit nurses at CUSP team meetings. … The nurse manager supports CUSP activities by communicating the CUSP team’s needs to the unit nurses. … contact for the unit nurses and helps empower the unit nurses throughout the initiative.