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monahrq.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/hand-hygiene/hand-hygiene-slides.html
March 01, 2017 - Slide 3: Health Care Workers' Hands Spread Infections 1
1-3 million serious infections estimated to occur … Hand contamination may occur as a result of small undetected holes in gloves. … Hand contamination may occur during glove removal.
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monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-december2016.pdf
January 01, 2016 - TEAMSTEPPS 05.2Mod 1 05.2 Page 15
TeamSTEPPS®
Slide 15
Reducing Workplace
Violence
Where May Violence Occur … Violence may occur anywhere in the health care facility, but it
is most frequent in the following areas … Workplace Violence
Communication and Teamwork
Slide Number 13
Team Structure
Where May Violence Occur
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Tool_1_Be_Partner_508.docx
February 10, 2011 - Nurse shift changes occur when nurses who are going off duty share information about you with nurses
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
August 01, 2022 - Slide 1
Say:
When adverse patient events occur, the patient and their family are looking for
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_tools.docx
August 03, 2017 - Ensure timescales for assessing and preventing falls are tailored to when falls are most likely to occur … Observations at the bedside should occur at the time of day when most patients who are well enough would
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monahrq.ahrq.gov/hai/pfp/2014-final.html
January 01, 2018 - Skip to main content
An official website of the Department of Health and Human Services
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monahrq.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
September 01, 2013 - Introduction to Adverse Events
Say:
Adverse events occur when a patient is harmed as a result of … Rarely does an adverse event occur as a result of intent.
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
August 01, 2022 - not an isolated event, since there are many different points at which disclosure conversations can occur
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monahrq.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - Many areas for errors to occur
especially with increase in test volume. … These policy- and procedure-related events are more likely to occur
in a rapidly changing environment
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - Could this type of communication failure occur in the future during normal working conditions? … Why did they occur?
Is there any opportunity to overcome the barriers?
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monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
August 01, 2022 - In addition, learning about system vulnerabilities before they occur is critical. … The CANDOR Response Team is responsible for conducting a preliminary review, which should occur within … The preliminary review should occur at the event location. … understanding of the event: if individual interviews, appropriate information gathering, and observations occur … Please note that the bulk of the time and effort of the event review process should occur during the
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrs_slides/rrsslides.pdf
January 01, 2008 - criteria for
RRS activation
TEAMSTEPPS 05.2Mod 1 05.2 Page 32Page 32
RRS
Where can Detection occur … Detection can occur from a variety of
sources or concerns
TEAMSTEPPS 05.2Mod 1 05.2 Page 33Page … EVALUATIONEVALUATION
TEAMSTEPPS 05.2Mod 1 05.2 Page 42Page 42
RRS
Evaluation: Debriefs
Debriefs occur … Identify Your RRS Structure
RRS Execution
Detection
Detection: STEP Assessment
Where can Detection occur
-
monahrq.ahrq.gov/hai/pfp/2015-interim.html
December 01, 2016 - Skip to main content
An official website of the Department of Health and Human Services
Careers
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monahrq.ahrq.gov/news/newsletters/e-newsletter/828.html
August 01, 2022 - An estimated 250,000 diagnostic errors occur annually in U.S. hospitals. … interactions are responsible for up to 14 percent of adverse drug reactions in hospitalized patients and occur
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
December 01, 2016 - Final Data From National Efforts To Make Care Safer, 2010-2014
December 2016
Saving Lives and Saving Money: Hospital-Acquired Conditions
Update
Final Data From National Efforts To Make Care Safer, 2010-2014
Summary
Final estimates for 2014 show a sustained 17 percent decline in hospital-acquired conditions…
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monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - community and the public on the estimation that
between 48,000 and 98,000 deaths from medical errors occur … Yes:
Did any of the following occur during hospitalization? … Yes:
Did any of the following occur during the hospitalization (check all that apply)
∗ Death
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monahrq.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
March 01, 2017 - Slide 17: For Information Transfer – Handoffs
Say:
Handoffs occur during a change in assignment … A handoff may occur when a resident is first welcomed to the nursing home from the hospital or during … another staff member, even for a short timespan such as a lunch break, a structured communication should occur
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monahrq.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
January 01, 2024 - Resources
AHRQ Papers on Diagnostic Safety Topics
Diagnostic errors occur
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monahrq.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
September 01, 2022 - Medicine report, To Err Is Human , revealed more than 15 years ago the extent of medical errors that occur
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monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-dec2013.pptx
January 01, 2013 - Technology Example
“…if [people] accept the need to adopt a particular practice, implementation should occur … ☐
Yes
☐
No
When
did
the
briefing
occur?