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101. Tool: Check-Back (or Repeat-Back) | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
     July 01, 2023 - patient harm are often caused by a provider overlooking messages alerting them to a test result or occur

102. Patient Safety Awareness Week 2022 | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/patient-safety/news-events/psaw-2022/index.html
     July 01, 2022 - Thomas, M.D., M.P.H., " Understanding Where, Why, and How Diagnostic Errors Occur " AHRQ PSNet Primer

103. Section 1: Overview of Key Concepts and Tools | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/teamstepps-program/curriculum/communication/overview/index.html
     June 01, 2023 - This step is particularly crucial for handoffs that occur electronically (e-handoffs).

104. Selected Best Practices and Suggestions for Improvement (pdf file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 2016 - Education should occur upon hire, annually, and when this protocol is added to job responsibilities.

105. Advanced Methods in Delivery System Research – Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #4: Formative Evaluation
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar04/formative_evaluation_webinar.pptx
     July 15, 2013 - Advanced Methods in Delivery System Research – Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #4: Formative Evaluation Advanced Methods in Delivery System Research – Planning, Executing, Analyzing, and Reporting Research on Delivery System Improvement Webinar #4…

106. Module 5: Situation Monitoring
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module5-situation-monitoring.pptx
     January 10, 2022 - problems that arise when understanding and expectations are out of sync.    6 Slide Where do failures occur

107. TeamSTEPPS 2.0 Module 2: Team Structure
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule2.pptx
     February 09, 2006 - how to prepare to deliver this module Module 2: Team Structure ‹#› of 25 Teamwork cannot occur … It is important to identify and recognize the structure of teams because teamwork cannot occur in the … Where did the breakdowns occur? … Now, where did the breakdowns occur between the components of this multi-team system?

108. TeamSTEPPS® Diagnosis Improvement: Module 4 Leadership - Facilitator’s Notes (pdf file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module4-presenters-notes.pdf
     January 05, 2022 - When and where does clinic/site‐level quality improvement planning occur now? 2. Who attends? … They occur after an event or shift and are designed to improve teamwork skills.

109. Situation Monitoring (Instructor Guide) (pdf file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.pdf
     February 12, 2014 - information must be communicated, a leader must be clearly designated, and mutual support must occur … Here are some examples of where failure can occur in the STEP process: • Status of the Patient: … It is important to establish the expectation that these team events will occur and that all team members

110. Strategy 3: Bedside Shift Report (Tool 3)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/strat3_tool_3_pres_video_508.pptx
     July 23, 2010 - disclosed for: Treatment Health care operations Payment HIPAA acknowledges incidental disclosures may occur … Bedside Shift Report (Tool 3) The HIPAA privacy rule recognizes that incidental disclosures might occur … Shift Report Training (Tool 3) Addressing HIPAA concerns (continued 3) Oral communications often must occur … Bedside Shift Report (Tool 3) The HIPAA Privacy Rule recognizes that oral communications often must occur

111. TeamSTEPPS 2.0 Module 6: Mutual Support
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule6.pptx
     February 09, 2006 - which information must be communicated, a leader must be clearly designated, and mutual support must occur … behavior) Informational Interpersonal Module 6: Mutual Support ‹#› of 45 Because conflict can occur … in teams, 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?

112. Improving the Safety of Diagnosis and Therapy in the Inpatient Setting | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
     February 01, 2024 - 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 …

113. TeamSTEPPS Fundamentals Course: Module 7. Summary | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/teamstepps/instructor/fundamentals/module7/igsummary.html
     March 01, 2014 - which information must be communicated, a leader must be clearly designated, and mutual support must occur

114. Strategies for Improving Patient Experience with Ambulatory Care: Service Recovery Programs (pdf file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-p.pdf
     November 02, 2017 - Recovery Programs November 2017 6.P-4 The Axioms of Service Recovery When problems with service do occur—and

115. Chlorhexidine Bathing Routine Reduces Infections in Nursing Homes | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsroom/press-releases/chlorhexidine-bathing.html
     October 01, 2023 - healthcare-associated infections (HAIs) such as MRSA, bloodstream infections, and urinary tract infections occur

116. AHRQ Views Blog: A Boost for Health Services Research | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/newsletters/e-newsletter/820.html
     June 01, 2022 - 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 …

117. Toolkit for Engaging Patients To Improve Diagnostic Safety  | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/diagnostic-safety/tools/engaging-patients-improve.html
     July 01, 2022 - Toolkit for Engaging Patients To Improve Diagnostic Safety  Diagnostic errors occur

118. For American Heart Month, AHRQ Offers New Tools for Expanding Cardiac Rehabilitation | Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/news/blog/ahrqviews/heart-month-tools.html
     February 01, 2023 - Unfortunately, these missed opportunities occur far too often due to fragmentation in care.  

119. Agency for Healthcare Research and Quality
     patientregistry.ahrq.gov/research/publications/search.html?page=1
     September 01, 2022 - The brief focuses on the maternal events that occur during childbirth and up to a week postpartum, with

120. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
     patientregistry.ahrq.gov/sites/default/files/wysiwyg/topics/fed-IWG-dxsafety-Nov19mtg.pdf
     November 15, 2019 - Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committe…