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healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule3.pptx
December 01, 2005 - Miscommunication occurred in the scenario when the night shift failed to properly flag the patient's … resident's care, treatment and services, current condition, and any recent or anticipated changes that have occurred
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healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-xiao.html
November 01, 2022 - Xiao identified frequent errors that occurred during the placement of central lines or central venous
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healthcare411.ahrq.gov/teamstepps/instructor/essentials/implguide.html
November 01, 2018 - Skip to main content
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healthcare411.ahrq.gov/hai/tools/mvp/modules/vae/monitoring-fac-guide.html
February 01, 2017 - and objective outcome measures, and correctly apply VAE diagnostic criteria to determine if a VAE has occurred … Patients
Say:
We will now use the VAC criteria reviewed earlier to determine whether a VAC has occurred
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule4.pptx
March 10, 2006 - skills
Designed to improve outcomes
An accurate recounting of key events
Analysis of why the event occurred … When doing a debrief, what you really want to be able to do is accurately go through the events that occurred … and document them, analyze why an event occurred if that was a problem-- regardless, you want to know … by asking questions related to team performance
Recap the situation, background, and key events that occurred
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
January 01, 2019 - reductions seen in 2015, 2016, and 2017 compared with 2014, AHRQ
estimates a total of 910,000 fewer HACs occurred … That means approximately 1.8 million fewer HACs
would occur compared with the number that would have occurred … for
2018, and 2019 as the data become available.
12 Due to the transition from ICD-9 to ICD-10 that occurred … the number of events (HACs) for the full year of 2015.
13 Due to the ICD-9 to ICD-10 transition that occurred … discharges, i.e., the
number of HACs shown in 2015–2017 is based on the number of HACs that would have
occurred
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
May 20, 2016 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4k
Selected Best Practices and Suggestions for Improvement
PSI 14: Postoperative Wound Dehiscence
Why Focus on Postoperative Wound Dehiscence?
• Postop…
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healthcare411.ahrq.gov/news/newsletters/e-newsletter/828.html
August 01, 2022 - Source of Mental Disorder Spending
In 2019, 41.5 percent of medical spending for mental disorders occurred
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healthcare411.ahrq.gov/teamstepps/readiness/abouttips.html
April 01, 2016 - Skip to main content
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/nhguide/6_TK1_T2-Talking_with_Residents_Family_Members_checklist_version_Final.pdf
October 01, 2016 - Nursing Home
Antimicrobial Stewardship Guide
Educate & Engage Residents, Family
Toolkit To Educate and Engage Residents and Family Members
Tool 2. Talking With Residents’ Family Members—short checklist version
What are antibiotics?
• Antibiotics are medicines that fight infections caused by bacteria. Antibiot…
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
November 01, 2012 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4b
Selected Best Practices and Suggestions for Improvement
PSI 05: Retained Surgical Item or Unretrieved Device Fragment Count
Why Focus on Retained Fore…
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healthcare411.ahrq.gov/news/newsroom/case-studies/cquips1402.html
January 01, 2014 - "It's not about blaming them that an error occurred."
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healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
December 01, 2022 - Skip to main content
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/tool_rapidresponse-systems.docx
May 01, 2017 - It also helps everyone understand why the event occurred and how it could be prevented in the future. … rapid response
· Nature of assistance provided during response
· Whether a debriefing with primary team occurred
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healthcare411.ahrq.gov/news/newsroom/press-releases/significant-patient-safety-improvement.html
July 01, 2022 - This analysis is the most comprehensive evaluation to date of adverse events that occurred in hospitalized
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healthcare411.ahrq.gov/news/blog/ahrqviews/investing-in-primary-care.html
July 01, 2021 - The PROMIS Learning Lab is studying the disruptions in primary care that occurred due to COVID-19.
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healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
March 01, 2021 - patients’ goals and priorities with an emphasis on their understanding of what
contributed to and occurred
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healthcare411.ahrq.gov/teamstepps/instructor/fundamentals/module6/igmutualsupp.html
March 01, 2019 - Delivering feedback several weeks after poor performance has occurred is too late for it to be effective
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healthcare411.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
March 01, 2021 - Skip to main content
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healthcare411.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
October 01, 2021 - Skip to main content
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