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21. Office-Based Teams Instructor Guide
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module11/11_ts_office_impplan-ig.pptx
    January 20, 2006 - Write down the process steps as they currently occur and identify who is doing what, when, and with what … Outcome aims focus on changes that occur because your staff carries out the intervention. … Write down the process steps as they currently occur and identify who is doing what, when, and with what … Who will attend the training sessions; What skills you will teach; When the training sessions will occur … and for how long; Where the sessions will occur; How you will train (method of presentation, tools,

22. Adverse Drug Events Occurring in U.S. Hospitals | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/data/infographics/adverse-drug-events.html
    August 01, 2018 - 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 …

23. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
    October 01, 2021 - just a subset of the data that are out there, and we have enough to confirm that diagnostic errors occur … DM: Why do diagnostic errors occur in the first place? … This focus can occur even when their current patient’s history or symptoms suggest a different diagnosis … Systemic errors, in contrast, can occur when processes within organizations aren’t designed well or don

24. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/funding/grantee-profiles/grtprofile-bell.html
    March 01, 2022 - Diagnostic errors occur in part because diagnosis itself is a multi-layered process, potentially involving … Documentation errors occur frequently, with about one in five patients reporting a perceived serious … Bell and her team developed and tested the framework for patient-reported diagnostic breakdowns that occur

25. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/reports/liability/brock.html
    August 01, 2017 - interventions focused on patient safety generally have not proven effective. 2-4 When success does occur … Disclosure coaches strengthen clinician confidence and allow disclosure to occur in a timely fashion. … Our organizations’ leaders and stakeholders hold a shared vision that organizational change needs to occur … organization’s leaders and stakeholders hold a shared vision of what organizational change needs to occur … organization’s leaders and stakeholders hold a shared vision of how organizational change needs to occur

26. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - Say: Errors occur within the health care setting because health care professionals are human, and humans … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

27. Surge in Drug Shortages Occurred in Wake of Pandemic, Study Finds | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/news/newsletters/e-newsletter/908.html
    April 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 …

28. Slide 1
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module11/11_ts_office_impplan.pptx
    January 20, 2006 - When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

29. PowerPoint Presentation
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module11/ts2-0ltc_module11_slides_implementation.pptx
    February 03, 2006 - When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

30. Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps/instructor/reference/quickrefguide.html
    March 01, 2014 - achieved, who will be involved (whose behavior will change), and when and where the change will occur … Write the process steps as they currently occur, identifying who is doing what, when, with what tools … each trainee audience, including who will attend, what will be taught, when and where sessions will occur

31. AHRQ Tribal Consultation Policy | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/cpi/about/mission/strategic-plan/tribal-consultation-policy.html
    August 01, 2014 - Policy It is the policy of AHRQ that consultation with Federally-recognized Indian Tribes will occur … Consultation shall occur on a regular basis and may occur on an "as needed" basis as well. … The Agency will also take part in the Department's annual national Tribal budget consultations which occur … Other types of meetings and/or conferences occur in which tribal leaders/representatives and Agency leaders

32. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
    February 01, 2015 - mistakes safely, and to learn from these mistakes while avoiding patient harms that might otherwise occur … More focused forms of feedback with the guidance of an instructor are likely to occur during a debrief … clinicians’ inquiries, they may evoke a wide range of emotional and behavioral characteristics that occur … Because of the uncertainty, complexity, and rapidly emerging conditions that occur in many health care … Given that unexpected events will occur, there are lessons to be learned regarding their anticipation

33. Data Measures Guide (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/datameasures-guide.pdf
    January 01, 2017 - , o 3 have adverse event (9) occur, o 2 have adverse event (18) occur, and o 3 have adverse event … (20) occur. … ) occur and 30% of the patient days had adverse event (20) occur Target Accurate documentation of … (20) occur. … ) occur and 30% of the patient days had adverse event (20) occur Target Accurate documentation of

34. The Quick Reference Guide to TeamSTEPPS Action Planning | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps/instructor/essentials/implguide3.html
    November 01, 2018 - achieved, who will be involved (whose behavior will change), and when and where the change will occur … during which the problem, challenge or opportunity occurs - write the process steps as they currently occur … trainee audience including who will attend, what will be taught, when and where sessions will occur

35. FileNewTemplate
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module1.pptx
    March 01, 2010 - Objectives After completing this module, you will be able to: Describe the impact of errors and why they occur … ‹#› After completing this module, you’ll be able to: Describe the impact of errors and why they occur … , and have a shared understanding of how a procedure should happen in order to identify when errors occur … Module 1 Summary In this module you learned to: Describe the impact of errors and why they occur Describe … Module 1: Introduction ‹#› In this module, you learned to: Describe the impact of errors and why they occur

36. Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/antibiotic-use/acute-care/four-moments/index.html
    November 01, 2019 - This can occur as early as after the first day the patient is on antibiotics; thus, the Moment 3 questions … Moment 4 should occur when the patient’s diagnosis becomes clear.

37. Module 11 Instructor Slides (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module11/ts2-0ltc_module11_slides_implementation.pdf
    June 09, 2017 - ■ When and where will the improvements occur? … When will the training sessions occur and for how long? Where will the sessions occur?

38. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
    May 20, 2016 - Recommended Practice: Postoperative Wound Assessment • Documentation of the surgical wound should occur … 48 hours after surgery to establish a baseline.1,2,7 • Repeat assessment should occur every shift … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.1

39. Module 2 Instructor Slides (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module2/ts2-0ltc_module2_slides_team.pdf
    June 12, 2017 - teams interact is critical for implementation planning Team Structure • Teamwork cannot occur … Mod 2 LTC 2.0 Page 16 • Ancillary and support services • Where did the breakdowns occur between the

40. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
    November 01, 2012 - foreign objects can include perforation of the bowel, sepsis, and even death.1 These complications can occur … o A manual inspection of the incision site should occur, along with inspection of the surrounding surgical … Education should occur upon hire, annually, and when this protocol is added to job responsibilities.2 … performing a failure mode and effects analysis to better understand the process and where breakdowns occur