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talkingquality.ahrq.gov/teamstepps/instructor/reference/teamattitude.html
April 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Teams that do not communicate effectively significantly increase their risk of committing errors.
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talkingquality.ahrq.gov/research/publications/search.html?page=17
March 01, 2010 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … It includes articles on reporting systems, risk assessment, safety culture, medical simulation, patient
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talkingquality.ahrq.gov/research/publications/search.html?page=11
December 01, 2014 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … It identifed factors associated with adult patients at high risk for ED discharge failure.
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talkingquality.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/northshore.html
March 01, 2021 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … recognized that despite their best efforts, they may not be identifying all of their patients who are at risk
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talkingquality.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/index.html
May 01, 2016 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer
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talkingquality.ahrq.gov/hai/tools/mvp/modules/vae/monitoring-fac-guide.html
February 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … VAP contributes to this mortality risk. … Possible Complications of Mechanical Ventilation
Say:
Mechanical ventilation puts patients at risk … increase in days to extubation and days to hospital discharge, but suffering a VAE doubles the patient’s risk
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module8/igchangemgmt.pdf
February 25, 2014 - They
should also encourage risk taking and nontraditional ideas,
activities, and actions. … solutions;
• Encouraging people to speak up, even to differing views;
• Encouraging people to take risks
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talkingquality.ahrq.gov/talkingquality/translate/scores/scoring.html
June 01, 2016 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … Some research indicates that a “negative” or “risk-oriented” frame for presenting information is more
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talkingquality.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
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talkingquality.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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talkingquality.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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talkingquality.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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talkingquality.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html
March 01, 2017 - Opportunity Guidance
AHRQ Grants Policy Notices
AHRQ Informed Consent & Authorization Toolkit for Minimal Risk … 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
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talkingquality.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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talkingquality.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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talkingquality.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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talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule8.pptx
March 28, 2006 - We're all at risk for this. … direction
Allow others to find their own team-driven solutions
Encourage others to speak up and take risks … They should also encourage risk-taking and nontraditional ideas, activities, and actions. … Encourage people to take risks. Affirm and refine the vision. Make room for others' ideas.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ahrq-network-factsheet.pdf
February 01, 2022 - especially vulnerable, and their reliance
on nursing home staff put these essential workers at high risk
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
August 28, 2012 - Having the Newborn Critical Care Center complete a falls risk assessment for each patient for each shift … , quantitative measures to evaluate can include the falls rate and the number of patients with fall risk … Solutions that are simple and designed with very little risk of failure contribute to the success of
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talkingquality.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