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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Learning From Defects Through Sensemaking: Facilitator Notes
AHRQ Safety Program for Surgery
Slide 1: Learning From Defects Through Sensemaking
Say:
This module focuses on the process of Learning From Defects Through Sensemaking.
Slide 2: Learning Objectives
Say:
At the end of this module, you w…
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www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/chsp_linkage_file_tech_doc.pdf
October 01, 2018 - of LI
Headings
Rule Name Status Description
Appropriate nesting Passed Appropriate nesting
Back
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - performance measures of harm, we often tend to layer and repeat improvement projects to get performance back
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs023793-gold-final-report-2021.pdf
January 01, 2021 - The system
would be reintroduced back into the MICU only after a number of changes with respect to improved
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - performance measures of harm, we often tend to layer and repeat improvement projects to get performance back
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hcup-us.ahrq.gov/reports/statbriefs/sb154.pdf
March 01, 2013 - passage to release spinal fluid)
32,957 6,633 20.1
3 Laminectomy, excision intervertebral disc (back
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psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
May 01, 2013 - AJ : Two things that have really held us back on progress on patient safety: one is incentives, which
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/preventive/chipra-0087-fullreport.pdf
October 01, 2016 - encounters for acute care, health
maintenance visits, or sports physicals all provide opportunities to teach … The eligibility criteria and
look-back period were altered slightly to allow for alignment with measure … The results of the measure can also be fed back to the provider via the EHR system to support
quality
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
September 01, 2017 - Visits Electronic Reports
Say:
This training will provide you with the information you need to teach … He had only been back at the facility for 2 days before he was transferred to the hospital.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/autism_disposition-comments.pdf
November 01, 2010 - Our intent with the
following sentence: "The goal of ABA is to teach new skills, promote
generalization … The common come-back to this objection is to use
parent-reports.
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www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appa.html
August 01, 2022 - Medical liability and accountability for safe care: Looking back, moving forward. Regis J.
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-27-ehr-and-pcmh.pdf
January 15, 2025 - that are often customized include care gap reports that can be used by
care teams to call patients back … conducted to
determine why patients did not receive recommended services and is this information fed back
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/meditation_executive.pdf
January 01, 2014 - Some studies address symptoms related to the
primary condition (e.g., pain in patients with low back … mental health/psychiatric
conditions (e.g., anxiety or stress) and physical conditions
(e.g., low back … A mind-body program
for older adults with chronic low back pain: results of a pilot study.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
December 01, 2017 - you will measure success
Put an audit plan in place to track that measure
Include a way to feed data back
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www.ahrq.gov/data/apcd/envscan/findings.html
July 01, 2022 - post-hospitalization),
Coronary artery disease (1 year chronic; 1 year post-revascularization),
Lower back … Capitation fees
Information on service provider
Administrative fees
Prescribing physician
Back
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015009-ward-final-report-2008.pdf
January 01, 2008 - HIT Interest Group members shared approaches and recommendations and discussed
approaches for secure back-up
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www.ahrq.gov/sites/default/files/2024-05/gore-report.pdf
January 01, 2024 - Back A, Arnold R, and Tulsky J: Mastering communication with seriously ill patients, 1st ed: Cambridge
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case6.html
November 01, 2014 - So we work from the operations [target] back[wards]." … As part of the training, management engineers and Six Sigma Black Belts teach a segment on the process … It's almost like they just want a bullet point outline that they think they can take back and implement
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
June 01, 2013 - Safety
Reduce Medical Error
Reducing Medical Error
Reducing Patient Injuries
Safer Patients
Teach … Information not available
Content
Evidence-Based: Yes
Content Areas: Communication improvement; read-back … 4
630 Communication Improvement 179
631 -- Communication between Providers 30
632 ---- Read Back
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blike.pdf
January 01, 2003 - Laryngoscope 1 1
ETT 1 1
stylet 1 1
Reversal drugs Narcan 1 1
Flumazenil 1 0
Call for Help Back-up