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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-yount-sops-action-planning-tool.pdf
June 01, 2019 - • Situation-Background-Assessment-
Recommendation (SBAR)
39
4. Who will be affected, and how?
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www.ahrq.gov/es/nursing-home/resources/search.html?page=4
January 01, 2022 - COVID-19 Resources Catalog for Nursing Homes
AHRQ provided free training and mentorship to nursing homes across the country through the National Nursing Home COVID-19 Action Network . The Network supported the implementation of evidence-based prevention and safety practices within nursing homes to protect residents…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/008-ss-contact-precautions.pptx
April 01, 2025 - Program for MRSA Prevention: Targeting SSI | Surgical Services
Contact Precautions
22
Case Example:
Monitoring … professional judgment and standards of care in regard to the unique circumstances that may apply in each situation
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www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-specialized-populations-icu-slides.html
December 01, 2017 - Underneath the drawing is the phrase "What looks like a people problem is often a situation problem". … retention protocol
Insertion and maintenance competency evaluations
ED and OR -> ICU processes
Monitoring … Last patient of the morning (11:45 a.m.)
75 yo M
Hx of HTN, DM2
Admitted 24 hours earlier “for monitoring … are at high risk for a sacral decub”
“They are at risk for abdominal compartment syndrome and I’m monitoring
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/chlorhexidine-bathing.pdf
April 01, 2022 - Conversation Starters
Use SBAR (Situation-Background-Assessment-Recommendation or Request) to raise … A sample script could be:
Situation: Our ICU has worked diligently to reduce our CLABSI rates, but
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
June 11, 2003 - Data collected
provides feedback to department heads, allowing for monitoring, systems
improvement, … The
department heads are able to determine if personnel need monitoring, systems
need improvement,
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www.ahrq.gov/talkingquality/assess/evaluation-plan.html
January 01, 2023 - you are evaluating your results, you may also need to start early if you hope to collect data on the situation … Semi-structured interviews are more common; in such interviews, interviewers can reword the questions to fit the situation … When you are collecting primary data, you typically have to develop tools specifically for your situation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Dingley_14.pdf
February 06, 2008 - efforts—such as crew resource management (CRM) and a focus on the key concepts of
leadership, briefings, monitoring … SBAR is an acronym for:
• Situation: What is going on with the patient? … Be clear, concise, focus on the
problem & only report what is relevant to the current situation! … Situation: 5-10 second “punch line” – What is happening now? … for this purpose, resulting in
ambiguities in the decisionmaking process for each type of patient situation
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_1-introduction.pptx
July 01, 2023 - Leads
SPPC-II
SCRIPT
Every birth unit and outpatient triage area needs to prepare for the emergency situation … additional 10 mg of IV hydralazine (Apresoline).
22
Severe Hypertension
Master Case
23
Fetal monitoring … Alice Smith, the patient
Hospital AIM
Team
Leads
SPPC-II
SCRIPT
In the meantime, fetal monitoring
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/103-how-to-integrate-cusp-approach-periop-fg.docx
April 01, 2025 - distributing CUSP cakes (a.k.a. cupcakes) or UV glow sticks (to detect germs, like fluorescent gel monitoring … professional judgment and standards of care in regard to the unique circumstances that may apply in each situation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-transcript.doc
April 08, 2014 - Or perioperative monitoring in surgeries, what does this mean? … If someone needs fluid monitoring, offer either urinals, hats, or wings for these patients. … It’s the nurse lead in that situation. … So, this is an example that with hard work, we can reach a situation where the nurse will own the catheter … That’s a very difficult situation.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/building-teamwork-transcript.html
December 01, 2017 - Or perioperative monitoring in surgeries, what does this mean? … If someone needs fluid monitoring, offer either urinals, hats, or wings for these patients. … It's the nurse lead in that situation. … So, this is an example that with hard work, we can reach a situation where the nurse will own the catheter … That's a very difficult situation.
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-22-meetings.pdf
September 01, 2015 - Participants gather data, identify problems,
analyze the situation, and plan for action. … It also models internal quality improvement and continuous performance
monitoring. … • There’s a systematic approach to
analyzing the situation and looking for
solutions. … • No one is interested in how others see the
situation.
• People are attacked and blamed. … • What aspects of the setting or situation made a difference?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/123-mrsa-toolkit-implementation-guide.docx
October 01, 2024 - This toolkit discusses the promotion and monitoring of hand hygiene, proper use of personal protective … The toolkit can help you decide which intervention(s) will best suit your situation. … program, describes strategies and considerations of quality of cleaning monitoring methods, reviews … )
· Facilitator Guide (.docx)
One Pager: Environmental Cleaning: Monitoring Methods One-Pager (.docx) … One Pager: Who Should Take On the Task of EVC Monitoring?
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/about/impact-stories/better-approach.pdf
November 06, 2024 - believes most patients need more time and support before
they are ready to take steps to address their situation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/improving/improving-facnotes.docx
May 01, 2017 - properly structured patient care team enables and results from effective communication, leadership, situation … monitoring, and mutual support. … Briefings help teams monitor the situation and raise red flags when needed. … When the conversation starts with “STOP,” emotions are triggered and the situation is made worse. … the problem reaches this point and nothing changes, there should be a plan for the next step in this situation
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www.ahrq.gov/policymakers/chipra/demoeval/state-reports/index.html
March 01, 2019 - Reports from the States
This page includes reports and other resources produced by the CHIPRA quality demonstration States. Content is presented by State within each of the five grant categories and a new category, Cross-Cutting Initiatives, for materials that cross grant categories and States.
Contents
U…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
January 01, 2019 - guiding them through the
process, from the first stage of self-assessment to the final stage of ongoing monitoring … Handoffs & Transitions, #5, SBAR Tool: Situation-Background-Assessment-
Recommendation
Composite 9. … SBAR Tool: Situation-Background-Assessment-Recommendation
http://www.ihi.org/resources/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefi … SBARTrainingScenariosandCompetencyAssessment.aspx
12
• “SBAR Report to Physician About a Critical Situation … Handoffs & Transitions, #5, SBAR Tool: Situation-Background-Assessment-
Recommendation
http://www.ihi.org
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
March 06, 2025 - Case Study: Continuous Monitoring with Sedative and Analgesia Administration
Although they are important … 2007, responding to these risks,
Dartmouth-Hitchcock Medical Center implemented pulse-oximetry-based monitoring … 10-year retrospective review of rescue events and patient safety data demonstrated that
continuous monitoring … Inpatient Respiratory Arrest Associated with Sedative and
Analgesic Medications: Impact of Continuous Monitoring … The
acronym stands for:
• Illness severity
• Patient summary
• Action list
• Situation awareness
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-rev-0724update.pdf
July 01, 2024 - Cincinnati Children’s
Hospital Medical
Center
Cincinnati, Ohio
R18 HS29630
[Grant]
SAMURAI PICU:
Situation … Arrests In the
Pediatric ICU
2023-2028
$397,831
Purpose: To evaluate the use of the SAMURAI PICU (Situation … Arrests In the PICU) bundle to improve
early identification of high-risk patients, increase shared situation … Key Findings/Impact: GRAM triggered monitoring plans for a number of residents
among participating nursing … $20,323
Purpose: To develop and implement a 1-day preconference workshop, “Tools and
Methods for Monitoring