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121. Final Progress Report: Teamwork and Error in Neonatal Intensive Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/thomas2-report.pdf
     January 01, 2024 - Methods to measure these team-related behaviors are rudimentary. … Methods The methods are divided into four sections: focus groups, the development of behavioral markers … Qualitative data analysis methods were used. … It may occur between any of the providers (e.g., nurses can teach residents and vice versa). … We have now identified behaviors that are important in this environment, developed a method to measure

122. Final Progress Report: Verbal Order Policies, Occurrence, and Perceptions (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/wakefield2-report.pdf
     January 01, 2024 - Methods: A mixed-methods approach using document reviews and surveys was used to analyze VO policies … Finally, Wilson’s score method was used in conjunction with appropriate sampling weights and a finite … Nursing Policy/Procedure 4. Pharmacy Policy/Procedure 5. Hospital Policy/Procedure 6. … Physicians giving verbal orders do not like having the orders read back to them. 3.e. … Doing procedures. 5.c. Making patient rounds. 6.

123. Preventing CAUTI in Special Populations: Focus on Procedure-Related Catheter Use | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-proc-related-catheter-use-slides.html
     December 01, 2017 - Delivery (C-section) Electrophysiology/Cath lab Interventional Radiology (GU procedures) Ambulatory … compliance and exemption status with monthly rates of UTI among general and vascular surgery patients Methods … undergoing elective GU surgery: Varicocelectomy, inguinal herniorrhapy, scrotal surgery Methods … Reinsertion and UTI 18.8% 6.0% <0.001 Slide 41 Outcomes of Collection Fed data back … Data back to faculty to relieve some concerns regarding POUR (overwhelming sense was that POUR was >75%

124. Implementing the SPPC‐II Teamwork Toolkit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_7-implementation-speaker-notes.pdf
     July 01, 2023 - : Developing Role Plays • Choose a tool(s) you’d like to feature in a facilitation session Check‐Back … Debrief | Two‐Challenge and Power Words • Independently brainstorm different ways to interactively teach … If we’re successful today, you’ll all have a stack of ideas to take back to help you manage and plan … complete the whole Tier 1 training for your frontline providers (next slide), and then we will come back … Call‐Out and Chec Back Wave 2 3. SBAR 4. I PASS the BATON k Wave 3 5.

125. Morning Briefing and Shadowing (Transcript) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/briefing.html
     April 01, 2013 - developed their patient safety curriculum that we've been using for the last 7 years now, and I also teach … When you look at policies and procedures, you definitely see the two very divergent methods of thinking … It was identified because there was not a specific method of addressing problems that allowed for people … before -- you know that watch one, do one, teach one. … If they're too unstable to get through the procedure that they don't go.

126. Final Progress Report: Valuation of a Simple Tool for Chest Pain Patient Risk-Stratification in North America (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/mader-poronsky-report.pdf
     January 01, 2024 - Methods: This was a single-site, prospective, observational cohort study to test our ability to administer … Methods This was a single-site, prospective, observational cohort study to test our ability to administer … Include five headings: Purpose, Scope, Methods, Results, and Key Words 3. … Methods (Study Design, Data Sources/Collection, Interventions, Measures, Limitations) 6. … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

127. Eliminating CLABSI, A National Patient Safety Imperative: Final Report Companion Guide (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/clabsicompanion.pdf
     October 18, 2012 - ................................................................................... 27 Estimation Method … Within the Methods section, a data collection schedule and details on calculations can be found. … considered (e.g. costs billed, actual costs, etc.), and estimation model utilized (e.g. matching procedure … consumer price index inpatient hospital services index Data as of: October 15th, 2012 30 Estimation Method … beginning of the project quarter (i.e. month 1), the numbers of the first available month were carried back

128. Technical Interventions To Prevent CAUTI | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/guides/implguide-pt3.html
     October 01, 2015 - measurement of urinary output in critically ill patients —Indwelling urinary catheters are the only method … Use audits and observations of practice and ensure that collected data are reported back to staff doing … this procedure. … Use case scenarios to teach best use of the nurse-driven protocol for removal of catheters. … Teach about appropriate care of acute urinary retention that may occur.

129. Issue Brief 7. Improving Education: A Key to Better Diagnostic Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/dxsafety-issuebrief-education.pdf
     March 11, 2022 - diagnostic error, as repeated studies have shown.6, 27, 28 Some of the origins of this problem trace back … In addition, health professions education programs have been slow to adopt evidence-based methods to … , what to teach, how to teach it, and how to assess it? … training in this area should translate into specific skills and practices regarding effective listening, teach-back … Clinical reasoning assessment methods: a scoping review.

130. Final Progress Report: Improving Safety After Hospitalization in Older Persons on High-Risk Medications (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gurwitz2-report.pdf
     January 01, 2024 - other resources.37,38) The clinical pharmacist reviewed materials with the patient/caregiver, using teach-back … Teach-back is a way to confirm that a healthcare provider has explained to patients what they need to … Each review followed a standardized procedure, searching for signals possibly indicating a clinically … Observation method of detecting medication errors. … Always Use Teach Back! http://www.ihi.org/resources/Pages/Tools/AlwaysUseTeachBack!.aspx.

131. Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Woods_78.pdf
     July 23, 2008 - Focus groups have been shown to be an effective method for identification of systemic patient safety … Someone taking charge in a conflict 2 Coordination regarding medical equipment needed for surgical procedures … admitting a patient had every clinic note, every discharge summary on the computer, every radiologic procedure … I think it is good, because it gets us out of trying to go back and forth and be mediating something … Rounds—a time-honored method of clinical communication—were described as effective because this method

132. Cognitive Artifacts’ Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding of Daily Work (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Nemeth.pdf
     July 07, 2002 - A surgeon, for example, may come into the operating rooms, perform a single procedure, and leave. … The coordinator changes the projected end time for the procedure in A3 from 3:30 to “?”. … The method that is described in this paper provides a basis to develop and evaluate future IT systems … Qualitative research and evaluation methods. 3rd ed. … Methods to research acute care cognition Figure 3.

133. Two More “Es” and How To Spread (Transcript) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/how-to-spread.html
     April 01, 2013 - At that time, instructions will be given as to the procedure to follow if you would like to ask a question … And this may really offer you some new ideas and new methods, and they are going to be coming up with … In addition, we teach every single month, we teach IV classes, that is a 4-hour class that we teach how … Go back and redo your staff safety assessment again, if you need to. … jump back into it again with renewed vigor in January.

134. Final Progress Report: Safety Culture Research: Ways to improve existing methods (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/etchegaray-report.pdf
     January 01, 2024 - o Debriefings must occur and focus on getting results of a survey back to frontline staff, help them … o They could potentially use psychologists to help develop tools to teach HR. … include how to choose appropriate measures, how to create profiles, how to analyze data, how to get it back … For example, an RCA after a fall discovered that policies often developed with the “spray and pray method … o What are the detection methods of events?

135. Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-patient-safety.html
     May 01, 2024 - Appendix A: Approach and Methods 6.  … Internal Medicine Refines and evaluates a simulated intervention, which uses actors playing patients, to teach … recommending watchful waiting to patients who request low-value and potentially harmful imaging for low back … effective approaches for reducing HAIs, and help frontline clinicians better understand how to apply proven methods

136. Final Progress Report: Improving Patient Safety: Health Systems Reporting, Analysis and Safety Improvement Research Demonstrations (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
     January 01, 2025 - People prefer different methods of reporting and how they receive results back. … Accomplishments/Outcomes/Interventions: The data were reported back through the QI team within each … Work Remaining: • Improve usability of SES: • Revisions to falls and test, treatment, and procedure-related … Grant staff have also presented key findings back to the academic facility and continue to be an active … Tools: An educational presentation on safe prescribing practices, a standardized method for analyzing

137. Final Progress Report: Accountability and Health Safety – A Statewide Approach (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/thorpe-rask-report.pdf
     January 01, 2024 - Methods: NA Results: Goal 1 - Key Accomplishments 1. … Various comparative peer groups' reports are provided back to hospitals to evaluate their standing with … Tool • Falls Assessment Survey • Pressure Ulcer Self-Assessment • Diabetes Survey • DVT Policy and Procedure … Tool, Falls Assessment Survey, Pressure Ulcer Self-Assessment, Diabetes Survey, and DVT Policy and Procedure … of LI Headings Rule Name Status Description Appropriate nesting Passed Appropriate nesting Back

138. Implementing the SPPC-II Teamwork Toolkit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_7-implementation-speaker-notes.pdf
     July 01, 2023 - A common method is voting nonverbally, using this approach: • Tell each team member that they have 2 … : Developing Role Plays • Choose a tool(s) you’d like to feature in a facilitation session Check‐Back … Debrief | Two‐Challenge and Power Words • Independently brainstorm different ways to interactively teach … If we’re successful today, you’ll all have a stack of ideas to take back to help you manage and plan … complete the whole Tier 1 training for your frontline providers (next slide), and then we will come back

139. Final Progress Report: Identification and Dissemination of Best Practices for Patient-Centered Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/aboumatar-report.pdf
     January 01, 2024 - Methods High-performing hospitals were identified via analysis of publicly reported HCAHPS data for … elements of the care board include room number, physician and nurse phone numbers, medications, tests and procedures … The teach-back method is utilized during report to ensure that patient understood the reason for each … Provide examples of any processes, policies, or procedures that you have in place to ensure that all … Offered Incentives: Off Offered Incentives 2: Off Additional Info/Comments: Processes, Policies, and Procedures

140. Final Progress Report: Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/schnipper-report.pdf
     January 01, 2024 - Methods: The study was conducted between September 2011 and July 2014. … education, which emphasized approaches for effective patient communication, including use of the “teach-back … performing discharge medication reconciliation, performing discharge medication counseling 9 using the teach-back … method, and forwarding the discharge medication list to the next provider of care after discharge. … • Most successful efforts established workflow procedures around medication reconciliation that made