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www.ahrq.gov/teamstepps-program/curriculum/team/tools/huddle.html
May 01, 2023 - Monitoring and Modifying the Plan: Huddle
The Huddle is a tool for communicating adjustments
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www.ahrq.gov/sites/default/files/2024-12/johnson-report.pdf
January 01, 2024 - first three visits. (2)
Each consult should be tailored to the particular domains required by the situation … domain is a mandatory part
of the consult. (3) Each consult should be tailored to the needs of the situation … 76.2%; responses 2 and 3) stated that a palliative care consult should be tailored to the needs of the situation … We should aim
for completeness but sometimes we have to tailor to the situation. … of Delphi participants felt that a Palliative Care consult should be tailored to the
needs of the situation
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_6-coaching-speaker-notes.pdf
July 01, 2023 - prompting
• Includes demonstrating, reinforcing, motivating, and providing
feedback
• Requires monitoring … It requires routine monitoring and ongoing assessment of
performance. … Monitoring outcomes of
the coaching process and providing additional assistance when necessary. … Monitoring outcomes of
the coaching process and providing additional assistance when necessary. … This requires continual assessment and reassessment of the
person and situation.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_6-coaching-speaker-notes.pdf
July 01, 2023 - prompting
• Includes demonstrating, reinforcing, motivating, and providing
feedback
• Requires monitoring … It requires routine monitoring and ongoing assessment of
performance. … Monitoring outcomes of
the coaching process and providing additional assistance when necessary. … Monitoring outcomes of
the coaching process and providing additional assistance when necessary. … This requires continual assessment and reassessment of the
person and situation.
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-fac-guide.html
July 01, 2023 - Errors and slips in medication administration, fetal and maternal monitoring, and delays in responding … Maternal and fetal monitoring using uniform parameters at regular intervals. … Parameters for monitoring and provider notification. … Monitoring vital signs, including oxygen saturation and respiratory rate and pattern. … maternal or fetal status to the care team, for checking back on orders given and received in an urgent situation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-mgso4.docx
May 30, 2013 - The use of uniform parameters for fetal and maternal monitoring and provider notification before and … Use uniform parameters for maternal and fetal monitoring at regular time intervals per unit-established … TeamSTEPPS®) (continued)
Key Perinatal Safety Elements
Examples/customizable components
Use SBAR (Situation … positive approach to emphasize “what is right, not who is right”:
D: Describe the specific behavior or situation … E: Express how the situation makes you feel or concerns you.
S: Suggest other alternatives.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/learning-from-antibiotic-adverse.docx
June 01, 2021 - Learning From Antibiotic-Associated Adverse Events
An antibiotic-associated adverse event is any event or situation … Did we try symptomatic treatment and active monitoring? … Can we try symptomatic treatment and active monitoring?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/sensemaking.pptx
May 01, 2017 - AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Sensemaking and Learn from Defects … Safety Program for Perinatal Care
Sensemaking &
Learn from Defects
Exercise
Think of an unexpected situation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-oxytocin.docx
May 01, 2017 - Use uniform parameters for maternal and fetal monitoring and provider notification prior to initiation … The use of the same uniform parameters for fetal and maternal monitoring and provider notification before … Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop … positive approach to emphasize “what is right, not who is right”:
· D: Describe the specific behavior or situation … .
· E: Express how the situation makes you feel or concerns you.
· S: Suggest other alternatives.
· C
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-mgso4.html
July 01, 2023 - The use of uniform parameters for fetal and maternal monitoring and provider notification before and … Use uniform parameters for maternal and fetal monitoring at regular time intervals per unit-established … Monitoring vital signs, including oxygen saturation and respiratory rate and pattern. … approach to emphasize "what is right, not who is right":
D: Describe the specific behavior or situation … E: Express how the situation makes you feel or concerns you.
S: Suggest other alternatives.
-
www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-4-slides.pdf
August 19, 2021 - Informs the implementation of a workable
automatic referral system as well as the
structuring and monitoring … Who will handle monitoring and reporting?
How will you fill the roles? … If no success, revisit the
process workflows, adjust
and try again
23
Story From The Field: Situation … Rehab program
will accommodate the forthcoming growth.
24
Story From the Field: Diagnosing the Situation … 27
PARTICIPANTSEVIDENCE-BASED
APPROACH
MONITORING
• Track measures over time
• Create a measure dashboard
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/module-4-slides.pptx
March 01, 2017 - Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity Brief
Huddle
Debrief
STEP
Cross-Monitoring … Situation awareness maintained?
Workload distribution equitable? … /CAUTI Long-Term Care Safety Modules
Teamwork and Communication | ‹#›
15
Practicing SBAR3
Situation … curriculum-tools/teamstepps/longtermcare/video/11cus_sa/index.html
20
DESC
Describe the specific situation … or behavior; provide concrete data
Express how the situation makes you feel/what your concerns are
Suggest
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-facilitator-roadmap.pdf
February 01, 2022 - ■ Module 2: Diagnostic Team Structure
■ Module 3: Communication
■ Module 4: Leadership
■ Module 5: Situation … Monitoring
■ Module 6: Mutual Support
■ Module 7: Putting It All Together
Present self-paced
learning
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html
September 01, 2022 - What further tests or monitoring might be helpful to understand what is really going on with the patient … Have you and your team been able to speak up if you have concerns related to this patient diagnosis or situation … your organization share the near-misses, errors, and excellent diagnostic performance from a clinical situation … Who should attend a debriefing of a clinical situation?
S-3.
-
www.ahrq.gov/teamstepps-program/evidence-base/anesthesiology.html
May 01, 2023 - Situation awareness in anesthesiology. Human Factors 37, 20-31. … Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
May 01, 2017 - with fetal condition per National Institute for Child Health and Human Development electronic fetal monitoring … risk awareness for all patients, timely recognition of a shoulder dystocia diagnosis, awareness and monitoring … Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop … positive approach to emphasize “what is right, not who is right”:
· D: Describe the specific behavior or situation … .
· E: Express how the situation makes you feel or concerns you.
· S: Suggest other alternatives.
· C
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-6.html
July 01, 2023 - effectively complete their assigned tasks (e.g., taking a careful history and physical examination, monitoring … Continued monitoring by the model may provide updates about the patient's status after an intervention … Patients, their families, or other caregivers must be comfortable describing their unique situation and … In this situation, a clinician would need to be familiar with the validity, reliability, and intended … However, this situation is changing as EHRs, hubs for healthcare communication, are increasingly incorporating
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - Cross-monitoring: A harm error reduction strategy that involves monitoring actions of
other team members … SBAR (Situation, Background, Assessment, Recommendation and Request): A
technique for communicating … Shared mental model: Results from each team member maintaining situation
awareness and ensures that … Situation awareness: The state of “knowing what’s going on around you.” … Situation monitoring: The process of continually scanning and assessing a situation to
gain and maintain
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - Cross-monitoring: A harm error reduction strategy that involves monitoring actions of
other team members … SBAR (Situation, Background, Assessment, Recommendation and Request): A
technique for communicating … Shared mental model: Results from each team member maintaining situation
awareness and ensures that … Situation awareness: The state of “knowing what’s going on around you.” … Situation monitoring: The process of continually scanning and assessing a situation to
gain and maintain
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/tool-safe-oxytocin.html
July 01, 2023 - Use uniform parameters for maternal and fetal monitoring and provider notification prior to initiation … Use unit-established parameters for maternal and fetal monitoring at regular intervals. … Parameters for monitoring and provider notification. … approach to emphasize "what is right, not who is right":
D: Describe the specific behavior or situation … E: Express how the situation makes you feel or concerns you.
S: Suggest other alternatives.