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41. Ldusafety Facguide (doc file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
    May 01, 2017 - Errors associated with schematic tasks are labeled “slips” and occur because of lapses in concentration … Errors associated with failures of attentional behavior are labeled “mistakes” and often occur because … Checklists are cognitive aids that have numerous practical benefits, including reducing slips that occur … In practice, steps listed may not occur sequentially.

42. TeamSTEPPS 2.0 Module 3: Communication
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule3.pptx
    December 01, 2005 - communicated, the importance of a clearly designated leader, and the fact that mutual support must occur … So just the shift change alone, that was 48 hand-offs that occur a day. … So there's huge opportunity for error to occur. … Where might miscommunication occur in this situation? And what are the possible outcomes? … Remember, we talked about over 150 times a day, in one 24-bed ICU, hand-offs occur.

43. 6 Tk1 T1-Talking With Residents Checklist Version Final (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T1-Talking_with_Residents_checklist_version_Final.pdf
    October 01, 2016 - There are five potential health problems that occur as a result of taking an antibiotic. 1.

44. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdf
    November 09, 2017 - Falls that occur within 1-7 days of the report date will be noted in high risk based on change of condition … Falls that occur within 1-7 days of the report date will be noted in high risk based on change of condition … Likewise, if multiple minor injuries occur, they will only be counted as one and if multiple major … injuries occur, they will only be counted as one. … Regardless of whether the report is monthly or quarterly, a room change must occur within 30 days

45. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
    January 01, 2024 - This focus has grown, largely as a result of the increasing realization that medical errors occur much … Methods STUDY DESIGN Overview of the ASIPS Design Errors occur in a broad spectrum of situations and … two levels of data helped us work toward a comprehensive understanding of how and why medical errors occur … After carefully analyzing the types of errors that occur, we developed a set of interventions with the … These highlighted a particular safety concern that could occur in any practice and offered suggestions

46. Labor and Delivery Unit Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety-fac-guide.html
    July 01, 2023 - Errors associated with schematic tasks are labeled "slips" and occur because of lapses in concentration … Errors associated with failures of attentional behavior are labeled "mistakes" and often occur because … Checklists are cognitive aids that have numerous practical benefits, including reducing slips that occur … In practice, steps listed may not occur sequentially.

47. Tips and Suggestions for Enhancing Organizational Readiness | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/teamstepps/readiness/abouttips.html
    April 01, 2016 - 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 …

48. Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
    March 08, 2019 - Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care March Meeting Summary Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on Appropriations requested t…

49. USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-audit-tool-userguide.pdf
    April 01, 2021 - USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities USER GUIDE: Hand Hygiene Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities Introduction This user guide provides step-by-step instructions for nursing home staff to use the Hand Hygien…

50. Prioritization Worksheet (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
    June 05, 2016 - Ideally, if your data permit, you would consider only costs that occur after the adverse event occurred

51. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072320.pdf
    November 06, 2020 - Taxonomy of diagnostic errors that could occur in the COVID-19 era, including false negatives and other

52. Strategy 3: Nurse Bedside Shift Report (Tool 1) (doc file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Tool_1_BSR_Broch_508.docx
    February 24, 2011 - Nurse shift changes occur when nurses who are going off duty share information about your care with nurses

53. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
    August 01, 2022 - 0026-2-EF. 1 e Introduction Each year, approximately 141 million emergency department (ED) visits occur … Thus, distributed cognition will not occur. … diagnostic process and a patient’s journey through the ED and may help prevent the anchoring bias that can occur … documented but solutions to the problem are sparse.44-46 For example, communication breakdowns can occur … Thus, it is no wonder that diagnostic errors occur.

54. Labor and Delivery Unit Safety (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
    May 01, 2017 - Errors associated with schematic tasks are labeled “slips” and occur because of lapses in concentration … Errors associated with failures of attentional behavior are labeled “mistakes” and often occur because … Checklists are cognitive aids that have numerous practical benefits, including reducing slips that occur … In practice, steps listed may not occur sequentially.

55. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
    March 01, 2021 - 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 …

56. TeamSTEPPS Fundamentals Course: Module 6. Mutual Support | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/teamstepps/instructor/fundamentals/module6/igmutualsupp.html
    March 01, 2019 - which information must be communicated, a leader must be clearly designated, and mutual support must occur … Return to Contents Conflict in Teams Say: Conflict can occur in teams and it is important to … know how to handle such situations when they occur. … Can we agree to follow such a procedure if this were to occur again?"

57. TeamSTEPPS Fundamentals Course: Module 3. Communication | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
    March 01, 2019 - which information must be communicated, a leader must be clearly designated, and mutual support must occur … Discuss findings with the group regarding root cause analyses from events that occur in your organization … Shift change—Transitions in care are the most significant time when communication breakdowns occur. … Discussion: Where might miscommunication occur in this situation?

58. AHRQ Tools To Reduce Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/hai/hac/tools.html
    March 01, 2024 - Hospitals and healthcare providers are focused on reducing specific HACs that occur frequently, can cause

59. TeamSTEPPS Training Evaluation Form (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-course-evaluation-form.pdf
    June 01, 2023 - Describe the impact of errors and why they occur 1 2 3 3.

60. How to Enter the Challenge | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/challenges/cds-connect/how-to-enter.html
    November 01, 2023 - Presentations will occur in January 2024.