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Job Aid: Presenting Performance Data (pdf file)

pbrn.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-presenting-data.pdf

May 17, 2021 -  Show where particular events occurred that might have a positive or negative impact.
AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts in the 21st Century | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/research/findings/making-healthcare-safer/index.html

July 01, 2023 - SHARE: More topics in this section Research Publications & Products Research Findings & Reports Grantee Final Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets National Healthcare Quality & Disparities Rep…
Tips and Suggestions for Enhancing Organizational Readiness | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/teamstepps/readiness/abouttips.html

April 01, 2016 - SHARE: More topics in this section TeamSTEPPS® About TeamSTEPPS® Readiness Assessment Curriculum Materials TeamSTEPPS® 2.0 Online Master Trainer Course Research/Evidence Base TeamSTEPPS® Webinars Tips and…
Improving the Safety of Diagnosis and Therapy in the Inpatient Setting | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html

February 01, 2024 - process failures (DPFs) in a cohort of representative cases. 1 Most of the significant DPFs (63.3%) occurred
Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html

December 01, 2022 - SHARE: More topics in this section Funding & Grants Notice of Funding Opportunities Research Policies Funding Priorities Training & Education Funding Grant Application, Review & Award Process Post Award Grants Management AHR…
TeamSTEPPS Implementation Guide | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/teamstepps/instructor/essentials/implguide.html

November 01, 2018 - SHARE: More topics in this section TeamSTEPPS® About TeamSTEPPS® Curriculum Materials TeamSTEPPS® 2.0 TeamSTEPPS® Rapid Response Systems Guide Training Guide: Using Simulation in TeamSTEPPS® Training Patients with Limited English …
Register Now: July 25 Webinar by National Action Alliance Will Address Involving Patients and Families in Safety | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/news/newsletters/e-newsletter/872.html

July 01, 2023 - Two new AHRQ issue briefs describe the importance of patient engagement after a diagnostic error has occurred
newbref

pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module11/m11impguide.pptx

February 03, 2006 - newbref TeamSTEPPS Implementation Guide TEAMSTEPPS 05.2 Page ‹#› Implementation Guide 1 Page ‹#› Shift Toward a Culture of Safety TEAMSTEPPS 05.2 Page ‹#› Implementation Guide 2 Page ‹#› 10 Steps of Implementation Planning Create a Change Team Define the problem, challenge, or opportunity for improv…
Prioritization Worksheet (pdf file)

pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf

June 05, 2016 - Ideally, if your data permit, you would consider only costs that occur after the adverse event occurred
TeamSTEPPS 2.0 Module 11: Implementation Planning

pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule11.pptx

November 02, 2018 - They also realized that calling a huddle when a fall occurred was an important step in their process. … baseline before implementation, and then evaluate after implementation to see if the desired changes occurred
Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)

pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf

April 27, 2022 - diagnosis later turned out to be wrong (e.g., a case in which an undesirable diagnostic outcome had occurred … Missed elevated BP occurred when a provider failed to document an appropriate action for a patient with … assumed diagnosis later turned out to be wrong (i.e., in which an undesirable diagnostic outcome had occurred … or commission (doing something wrong) exists at the particular point in time at which the “error” occurred … In the articles that did include the NASEM definition (n = 52), most mentions occurred in the in- troduction
Tool 1: Readmission Data Analysis and Interpretation (xls file)

pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx

September 20, 2016 - discharges for a given 1-year period, less exclusions listed below • Numerator: all hospitalizations that occurred
Federal Interagency Workgroup--Diagnostic Safety: November Meeting Summary (pdf file)

pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-nov2022.pdf

March 01, 2023 - Workgroup Summary: The latest workgroup meeting occurred virtually on November 3, 2022, and was attended
Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html

October 01, 2021 - SHARE: More topics in this section News Newsroom Blog AHRQ Views Newsletter Events AHRQ Views: Blog posts from AHRQ leaders Advancing Diagnostic Safety: An AHRQ Leadership Conversation OCT 25 …
TeamSTEPPS 2.0: Module 11. Implementation | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/teamstepps/instructor/fundamentals/module11/slimplement.html

March 01, 2014 - SHARE: More topics in this section TeamSTEPPS® About TeamSTEPPS® Curriculum Materials TeamSTEPPS® 2.0 TeamSTEPPS® Rapid Response Systems Guide Training Guide: Using Simulation in TeamSTEPPS® Training Patients with Limited English …
Four Moments of Antibiotic Decision Making | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/antibiotic-use/acute-care/four-moments/index.html

November 01, 2019 - SHARE: More topics in this section Antibiotic Stewardship Toolkits Acute Care Hospital Toolkit Four Moments Posters and Screen Saver Develop and Improve Stewardship Program Develop Culture of Safety Around Prescribing Best Pra…
Grantees Focusing on Hispanic and Latino Populations | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/priority-populations/observances/hispanic-heritage/index.html

October 01, 2021 - SHARE: More topics in this section Priority Populations About Priority Populations Publications Resources Health Observances Grantees Focusing on Hispanic and Latino Populations Peter Yellowlees, M.D. “I …
Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality

pbrn.ahrq.gov/funding/grantee-profiles/grtprofile-bell.html

March 01, 2022 - SHARE: More topics in this section Funding & Grants Notice of Funding Opportunities Research Policies Funding Priorities Training & Education Funding Grant Application, Review & Award Process Post Award Grants Management AHR…
TeamSTEPPS 2.0 Module 3: Communication

pbrn.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
TeamSTEPPS Fundamentals Course: Module 6. Mutual Support | Agency for Healthcare Research and Quality

pbrn.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