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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield1.pdf
January 01, 1999 - Prologue -- Blueprints for Action
1
Prologue
Blueprints for Action
Mary K. Wakefield
In 1999, the Institute of Medicine report To Err Is Human: Building a Safer
Health System1 advanced a clear challenge to create safer environments in health
care. The message of the report has resonated ever since, from t…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-6.html
September 01, 2021 - Improving neonatal outcome through practical shoulder dystocia training.
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www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-ape4.html
September 01, 2013 - Bathing Process—Using All Cloths
Use all six cloths in the following order:
Cloth 1: Neck, shoulders
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www.ahrq.gov/es/hai/universal-icu-decolonization/universal-icu-ape4.html
September 01, 2013 - Bathing Process—Using All Cloths
Use all six cloths in the following order:
Cloth 1: Neck, shoulders
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4g_combo_psi10-postopmetaderangement-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.4g
Selected Best Practices and Suggestions for Improvement
PSI 10: Postoperative Physiologic and Metabolic Derangement
Why Focus on Postoperative Phys…
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www.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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4l_combo_psi15-accidentalpuncturelaceration-bestpractices.pdf
May 31, 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.4l
Selected Best Practices and Suggestions for Improvement
PSI 15: Accidental Puncture or Laceration
Why Focus on Accidental Puncture and Laceration?
• A…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-cord-prolapse.html
July 01, 2023 - initiatives, or commercial entities also offer sample simulations scenarios or "drills" related to shoulder
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
June 02, 2025 - Interrupt, shake her shoulder, and pull her quickly toward the crib.
e.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4c_combo_psi06-pneumothorax-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.4c
Selected Best Practices and Suggestions for Improvement
PSI 06: Iatrogenic Pneumothorax
Why Focus on Iatrogenic Pneumothorax?
• Iatrogenic pneumothora…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/patient-family-care-slides.html
March 01, 2017 - Image: Photograph of a patient in bed with care provider's hand on her shoulder; faces are not shown.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
September 01, 2021 - event,31 has been applied to improve the outcome of a variety of obstetric emergencies, including
shoulder … Improving neonatal
outcome through practical shoulder dystocia training.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar4_pu_skinassesst_final.pdf
April 01, 2011 - Normal Workflow
Each time you—
• Auscultate lung sounds or turn the patient,
check the patient’s shoulders
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4i_combo_psi12-dvt-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
Tool D.4i 1
Selected Best Practices and Suggestions for Improvement
PSI 12: Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT)
Why Focus on DVT/PE…
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www.ahrq.gov/hai/clabsi-tools/appendix-3.html
March 01, 2018 - Image: Photograph of a shoulder with a subclavian catheter inserted.
Slide 16.
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www.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
February 01, 2015 - other hand, use of simulation
resulted in attenuated amounts of skill decay in the management of
shoulder … Management of shoulder dystocia:
skill retention 6 and 12 months after training.
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www.ahrq.gov/research/findings/final-reports/stpra/stpraaparef.html
September 01, 2018 - Complications in arthroscopic shoulder surgery, Arthroscopy: The Journal of Arthroscopic and Related
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/rapid-response/rapid-response-fac-guide.html
July 01, 2023 - Inability to complete delivery (e.g., with a shoulder dystocia).
Cord prolapse.
Hypotension.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/aseptic-catheter-insertion-practices-inthe_ED_transcript.docx
June 02, 2015 - having a leadership who's actually there in the unit with you watching you as you work, not over your shoulder
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www.ahrq.gov/hai/cauti-tools/archived-webinars/aseptic-catheter-practices-ed-transcript.html
December 01, 2017 - having a leadership who's actually there in the unit with you watching you as you work, not over your shoulder