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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/trainershandouts_all.pdf
September 01, 2012 - encounter, they often are not empowered
to speak up when they recognize that a patient’s safety is at risk … Legal Rev Commentary Suppl Healthcare Risk Manage 2003(May 1-3).
7. … I improved my understanding of patient safety risks to
LEP patients
1 2 3 4 5
4. … care team before
seeing the patient where the team leader describes team roles, goals, plans, and risks … care team before
seeing the patient where the team leader describes team roles, goals, plans, and risks
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - Quality Forum states: “Healthcare organizations must systematically identify
and mitigate patient safety risks … 11 Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate
• Using an individualized assessment of risk … factors for each specific patient allows
categorization of operative mortality risk into low (l%-3%
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pcmh.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-fac-guide.html
July 01, 2023 - Be able to intervene to minimize risk of serious harm and further deterioration. … Probabilistic Risk Assessment.
Causal Tree Worksheet.
Interdisciplinary Case Reviews. … of transition communication techniques to ensure a shared mental model of plan of care and perceived risks
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
June 05, 2016 - Rate―Injury to Neonate: The existing literature on birth trauma
and injury to the neonate suggests multiple risk … Given this heterogeneity, creating one best practices form to address
the various risk factors would
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/quickrefguide.pdf
March 13, 2014 - Study the process to identify risk points where things could go wrong and lead to
a recurrence … and tools (e.g., brief, huddle, debrief, STEP, SBAR, and I
PASS the BATON) that would eliminate the risk
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-4/share-tool4.pdf
April 01, 2014 - Fill out complex forms
› Find providers and services
› Share their health history
› Understand risk … chronic illness
› Skip needed tests
› Underuse preventive health care
Some groups are at higher risk
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - QI and patient safety during a time when
they experienced an increase in patient load and higher
risk … for more high-risk patients than ever before, so it is even
more crucial that we do things right…it’ … It is a safe way to deal with high-risk situations. … This variation created a risk
of both time lags in patient care and miscommunication
among the care … However, as one project leader soon recognized, “If
we’re going to do a [hemorrhage] risk assessment
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - QI and patient safety during a time when
they experienced an increase in patient load and higher
risk … for more high-risk patients than ever before, so it is even
more crucial that we do things right…it’ … It is a safe way to deal with high-risk situations. … This variation created a risk
of both time lags in patient care and miscommunication
among the care … However, as one project leader soon recognized, “If
we’re going to do a [hemorrhage] risk assessment
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap5.doc
December 11, 2012 - , eye protection
· Assistant: Cap, mask, isolation gown and gloves, eye protection (if at risk
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
December 01, 2017 - Assessing Risk in Testing
We know that:
• The risk of an event is related to its frequency and the … • Balancing these two aspects of risk can be challenging. … • It is important to stay focused on office systems in managing risk. … Results
• The highest scores for “office total” show areas where staff have identified the
greatest risks … do not eliminate all errors.
• A failure to monitor automated processes may introduce patient safety risks
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pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-december2016.pdf
January 01, 2016 - Situation Monitoring
PATIENT AND STAFF SAFETY IS THE NUMBER ONE
PRIORITY
People working in high risk … Awareness-oriented design and training creates
Safety:
Reduce human errors and system failures
Minimize risk … Social Workers
Activity Therapists
Hospital Police
Psych Response Teams
Administration
Risk
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pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module11.pptx
March 07, 2019 - points
Implementing interventions aimed at eliminating risk points
Testing the intervention
Sustaining … to everyone who’s involved in the process.
15
Step 4: Design a TeamSTEPPS Intervention
List the risk … Flowchart or map the process during which the target problem/challenge/opportunity occurs
Identify risk … points
Determine which TeamSTEPPS tools or strategies would work best to eliminate the risk points … Then you can identify the risk points where things could go or do go wrong and lead to recurrence of
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/rapid-response/rapidresponse_facguide.pdf
May 01, 2017 - maternity patient who has deteriorated
physiologically; and
• be able to intervene to minimize risk … Form
• Root Cause Analysis
• Eindhoven Model
• Failure Mode and Effects Analysis
• Probabilistic Risk … transition communication
techniques to ensure a shared mental
model of plan of care and perceived risks
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/labordel.pdf
March 18, 2014 - communication techniques taught in this module could have avoided placing this
patient at unnecessary risk … s unfolding event, no one assumes leadership for the case and the patient is
placed at unnecessary risk … At exactly that moment, the Triage nurse receives a call that a high-
risk patient in acute distress … This high-risk
patient ties up three nurses, two residents, and a covering attending obstetrician for … Instructor Comments
In this situation, the RN team leader becomes aware of a potential risk for the
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pcmh.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/northshore.html
March 01, 2021 - recognized that despite their best efforts, they may not be identifying all of their patients who are at risk
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/evalguide/lepevalguide.pdf
September 01, 2012 - I improved my understanding of patient safety risks
to LEP patients
1 2 3 4 5
4. … care team before
seeing the patient where the team leader describes team roles, goals, plans, and risks … care team before
seeing the patient where the team leader describes team roles, goals, plans, and risks
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/webinars/webinar6_falls_sustainingpractices.pdf
January 01, 2013 - specific
interventions
for fallers
Examples of Process Measures
Percentage of—
• Patients at risk … – For instance, reward unit staff the first time they
complete a fall risk assessment form correctly
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pcmh.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html
March 01, 2017 - To achieve optimal outcomes, organizations must design systems that minimize risks. … It's important to reinforce behaviors that reduce risk and deter behaviors that increase risk. … All humans make mistakes, and it is important to differentiate between human error and at-risk behavior