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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/impworkbook.pdf
December 11, 2015 - clinical subject
matter
Understands the
processes of care within
workspace where
changes will occur … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe? … When will the improvement occur? Within what timeframe? … Write down the process steps as they currently occur and identify who is doing
what, when, with what
-
www.ahrq.gov/teamstepps/instructor/fundamentals/module4/exbriefing.html
March 01, 2014 - When will the briefing occur?
Where will the briefing occur?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module4/exbriefing.pdf
March 20, 2014 - When will the briefing occur?
iii. Where will the briefing occur?
B.
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses1.html
August 01, 2022 - References
Each year, approximately 141 million emergency department (ED) visits occur
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/066-dec-staff-faqs-safety-side-effects.docx
October 01, 2024 - However, as with any product, side effects may occur. … Local CHG side effects are rare, estimated to occur in 1% to 3% of patients. … For example, this may occur if CHG enters the ear canal, and the patient has a perforated (punctured)
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module4/ts2-0ltc_module4_briefing_exsheet.pdf
April 24, 2017 - When will the briefing occur?
iii. Where will the briefing occur?
B.
-
www.ahrq.gov/patient-safety/reports/liability/baker.html
August 01, 2017 - families in the care team and how to communicate with patients about the risks and mistakes that can occur … kinds of information should be disclosed regarding each event and explore how communication should occur … Second, we wanted to ascertain how patient and family and provider communication should occur to mitigate … Last, we interviewed 12 clinicians about the common failures that can occur leading to each event. … The highest level of agreement was for those failures that could occur during the Delivery phase for
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
February 01, 2017 - List contributing factors that make defects in care more likely to occur. … Why 1—Why did this contributing factor occur?
Why 2—Why did “Why 1” occur? … Why 3—Why did “Why 2” occur?
Why 4—Why did “Why 3” occur?
Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
January 01, 2017 - and second-order problem solving
List contributing factors that make defects in care more likely to occur … you identify contributing factors
Use the “5 Whys” technique
Why 1—Why did this contributing factor occur … Why 2—Why did “Why 1” occur?
Why 3—Why did “Why 2” occur?
Why 4—Why did “Why 3” occur? … Why 5—Why did “Why 4” occur? … Does it occur rarely or have a high likelihood of reoccurring?
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/allergies-slides.pptx
September 01, 2022 - testing or evidence of hemolysis (jaundice, dark urine) or thrombocytopenia (petechiae)
Most commonly occur … Serum sickness
Vasculitis
Palpable purpura
Joint pain
Urticaria
Lymphadenopathy
Fevers
Most commonly occur … Ambulatory Care
Allergy History: Timing3,12
How long after starting the antibiotic did the reaction occur … Type 1 allergies occur after the first or second dose
Other types usually occur days later
How long … ago did the reaction occur?
-
www.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/playbook.html
February 01, 2025 - CUSP can be implemented through CLABSI and CAUTI prevention practices, policies, and procedures that occur
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
August 01, 2022 - Thus, it is no wonder that diagnostic errors occur.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/facslides.html
December 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Communication: Reviews existing team meetings/huddles that occur at the facility. … When will the meeting occur?
Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining-slides.html
October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur?
Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facslides.html
September 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Communication: Reviews existing team meetings/huddles that occur at the facility. … When will the meeting occur?
Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
January 01, 2003 - Five
subscales emerged for “reasons why MAE occur”; four subscales emerged for
“reasons why MAE are … medication
administration errors occur. … Reasons why medication errors occur (19 items in 1994 and 29 in
subsequent surveys).
2. … In the first content area, “why MAEs occur,” five factors emerged. … Nurses’ perceptions of why medication administration
errors occur.
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-three-options.pdf
November 01, 2019 - Moment 4 should occur as soon as it is clear what infectious
process is being treated and the patient … Moment 4 should occur as soon as it is clear what infectious process is being
treated and the patient
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
October 01, 2017 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur?
Which reports will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
November 01, 2016 - Nursing homes investigate adverse events after they occur. … Is it possible to intervene before adverse events occur? … Analysis: Reviews process for conducting investigations or root cause analyses when adverse events occur … When will the meeting occur?
Which report(s) will be used at the meeting? … How will communication occur with other disciplines to confirm changes in care?
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-safety-chg-mupirocin.docx
March 01, 2022 - However, as with any product, side effects may occur. … Local CHG side effects are estimated to occur in 1–3 percent of patients.