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  1. monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-april2016.pptx
    January 01, 2016 - Coffey-Zern, Michael Vest, Loretta Consiglio-Ward, and Carol Kerrigan Moore, Christiana Care Health System … #› Conclusions TeamSTEPPS can improve clinical performance and patient safety in a multi-facility system
  2. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_fall-prevention.docx
    June 30, 2017 - Explore this hospital’s incident reporting system. … You may have an electronic incident reporting system that will make it easier to count the number of … ASK: What system do you currently use for incident reporting? … First, count the number of falls that occurred during the month from your incident reporting system. … Post-fall huddles are useful techniques for understanding reasons for failures in the system.
  3. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/e-fetal-monitoring_facguide.pdf
    May 01, 2017 - standard National Institute for Child Health and Human Development (NICHD) nomenclature and three-tiered system … NICHD also proposed a three-tiered system for EFM interpretation. … Use of the standard three-tiered system for interpreting and communicating FHR tracings provides a … and bedside reference aids that define and describe the 2008 NICHD nomenclature and three-tiered system
  4. monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module4-presenters-notes.pdf
    January 05, 2022 - preferences; act in their best interests and advocate for them; help them navigate the healthcare system … This support includes maintaining a reward system that reinforces good performance, an information system … that provides access to the data needed for the work, a system that offers relevant team training, … • Retrain and redesign = Is it system flaws or human flaws?
  5. monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/safe-electronic-fac-guide.html
    July 01, 2023 - standard National Institute for Child Health and Human Development (NICHD) nomenclature and three-tiered system … NICHD also proposed a three-tiered system for EFM interpretation. … Use of the standard three-tiered system for interpreting and communicating FHR tracings provides a common … cards and bedside reference aids that define and describe the 2008 NICHD nomenclature and three-tiered system
  6. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - report is received, the organization that has implemented the CANDOR process will activate the CANDOR system … Slide 18 Say: Once the CANDOR system is activated, two processes are occurring at the same time: … In this approach, the goal is to: Ask what is responsible, not who is responsible, and focus on system … Slide 24 Say: Human factors engineering is about redesigning the system within which humans work, … It explains that after an adverse event, regardless of whether it is due to human or system error, all
  7. monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-sept2015.pdf
    January 01, 2015 - Crossing the Quality Chasm: A New Health System for the 21st Century. … following event was reported to you (an authority figure) through your electronic event reporting system … would someone report the event to a responsible party or through an established event reporting system … Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System
  8. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
    May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant
  9. monahrq.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/key_drivers_descriptions.pdf
    February 01, 2019 - more QI resources to draw on and likely will need to align themselves with interests of the larger system … Creative use of other data sources such as a patient web portal, a laboratory system, a billing system … , or a practice’s paper-based system, may provide the best solution. … Using data that are already available in another system is often more efficient than investing time … systems may require the addition of new fields and paper-based systems will need a coherent coding system
  10. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_PFE_Benefits_Hosp_508.docx
    January 01, 2012 - bed capacity and reduce overcrowding, with engaged patients and families serving as an early warning system … Partnering with patients and families to design a patient-and-family-centered health care system. 2008 … Partnering with patients and families to design a patient- and family-centered health care system: a
  11. monahrq.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-p.pdf
    November 02, 2017 - complaints to front-line staff—but these staff do not necessarily have the skills or the resources to fix “system … • A clear system of resource people, clear authority lines, and backup systems for dealing with … in the operating room, flu season packs the appointment schedule, implementing a new call center system … specific person in the service process, which reflects a training problem, while others are the result of system … Commit to identifying failure points in the system • Using complaint data, identify failure points
  12. monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/healthited-issuebrief.pdf
    February 01, 2021 - home” portal may allow patients and their ED providers to review medical records from the external system … investigation.15,17 For example, patients seeking emergency care outside of their primary healthcare system … about test results and diagnoses from their ED visit with their PCP, if the PCP cannot access that system … Exploration of portal activation by patients in a healthcare system. … A mobile telephone-based interactive self-care system improves asthma control.
  13. monahrq.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/2-why-improve/cahps-section-2-why-improve-patient-experience.pdf
    May 01, 2017 - o Similarly, the Physician Quality Reporting System (PQRS) program administered by CMS includes a patient … o Starting in 2019, two new physician payment programs—a merit-based incentive payment system (MIPS) … health outcomes a year after discharge.10, 11 Measures of patient experience also can reveal important system
  14. monahrq.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/hand-hygiene/hand-hygiene-slides.html
    March 01, 2017 - Accessing the drainage system to empty the drainage bag or collect a urine sample. Why? … Then, gloves will contaminate the urinary catheter or urine collection system. … Accessing the drainage system to empty the drainage bag or collect a urine sample. Why?
  15. monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/guide.html
    September 01, 2017 - Explore this hospital’s incident reporting system. … You may have an electronic incident reporting system that will make it easier to count the number of … Ask: What system do you currently use for incident reporting? … First, count the number of falls that occurred during the month from your incident reporting system. … Post-fall huddles are useful techniques for understanding reasons for failures in the system.
  16. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar01/sl_fuzzyset.ppt
    May 14, 2013 - AHRQ Slide Template 2004 Advanced Methods in Delivery System Research – Planning, Executing, Analyzing … , and Reporting Research on Delivery System Improvement Webinar #1: Fuzzy Set Analysis Presenter: … Harrison, PhD Sponsored by AHRQ’s Delivery System Initiative in partnership with the AHRQ PCMH program … Harrison, PhD Sponsored by AHRQ’s Delivery System Initiative in partnership with the AHRQ PCMH program … Register for this and other events in our series on advanced methods in delivery system research, here
  17. monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
    August 01, 2022 - Essentially, distributed cognition describes how information is transformed and propagated throughout a system … The physical organization of work influences how information flows throughout a system. … itself is a specific category of distributed cognition because it defines the mechanism by which a system … This case revealed numerous system failures that contributed to the initial misdiagnosis and needless … Blame the pa- tient, blame the doctor or blame the system?
  18. monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-oct2013.pptx
    January 01, 2013 - About Patient Safety and LEP The Institute of Medicine Report To Err Is Human: Building a Safer Health System … To err is human: building safer health system. Washington: National Academies Press; 2000. … Crossing the quality chasm: a new health system for the 21st century.
  19. monahrq.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html
    March 01, 2017 - makes a mistake, it's viewed as an opportunity for the entire team to learn and improve the process or system … Hierarchies within teams should be eliminated, as it creates a system in which one person's input is … Slide 24: Just Culture 8,9 Say: The term "Just Culture" refers to a system of shared accountability … System design Humans are not perfect and occasionally make mistakes, either through unintentional errors … Slide 25: A Just Culture Say: A system of Just Culture recognizes that people make mistakes.
  20. monahrq.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2015_hp-chartbook.pdf
    January 01, 2015 - Chartbook are compiled from detailed data displays reported in the CAHPS Database Online Reporting System … Plan Survey Database are provided access to a secure, password-protected area of the online reporting system … The CAHPS Database Online Reporting System is updated annually with new data submitted by CAHPS Health … CAHPS Database Online Reporting System The CAHPS Database Online Reporting System is a Web-based platform … The reporting system consists of two major components: (1) a public site available to anyone with access

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