Interested in TeamSTEPPS Master Training? Courses Scheduled Across the Country!

Registration now open for TeamSTEPPS Master Training Courses for Hospitals

Registration for an AHRQ TeamSTEPPS Master Training Course for healthcare professionals at MetroHealth in Cleveland, on December 9 and 10 is now open.

Upcoming hospital Master Training Courses are planned for next year at the following AHRQ regional training centers: University of Tulane, New Orleans; University of California, Los Angeles; Northwestern University, Chicago; University of Washington, Seattle; Duke University, Durham, NC; MetroHealth, Cleveland; North Shore-Long Island Jewish Health System, Long Island, NY; and the University of Minnesota, Minneapolis, MN. Registration for these courses is open November 3. Others are being planned.   Go to the national project website for more information and updates.

TeamSTEPPS Training Courses Posted, TeamSTEPPS in Primary Care

The Center gets many questions about TeamSTEPPS training.   Nationally, Master Training Course information for 2015 is now available!  Registration for TeamSTEPPS Master Training Course for Primary Care, adapting the core concepts of TeamSTEPPS for primary care office-based teams, is available at   Additionally, general Master Training Course registration for classes January through May is expected to be available in early November at

AHRQ hosting webinar: Evidence Around Team Training & Patient Safety

The Agency for Healthcare Research and Quality (AHRQ) will host a 1-hour Web conference on January 8 from 1:00 p.m. to 2:00 p.m. ET on the use of the Agency’s teamwork training program, TeamSTEPPS ®, and what evidence is available to demonstrate the program’s efficacy in improving patient safety. David Baker, Ph.D., TeamSTEPPS ® Master Trainer and Senior Vice President at IMPAQ International, will discuss the following objectives: the key components of teamwork, how to develop teamwork in health care, the core components of TeamSTEPPS ®, the TeamSTEPPS deployment process, the evidence on team training effectiveness and the effectiveness of TeamSTEPPS   REGISTER

Resources to Improve Management of Complex Residents in Skilled Nursing

The Agency for Healthcare Research and Quality’s “Web M & M” this month addresses the challenge of managing increasingly complex residents in skilled nursing facilities.   In addition to a general discussion, the article includes a table (Page 4) outlining some of the most significant issues, along with strategies and resources to address those.  Here is a link to the article.    Among the tools:   TeamSTEPPS and workforce development using programs such as Just Culture, both offered by CPS for Missouri LTC organizations.

AHRQ Releases Latest M&M Cases

The Agency for Healthcare Research & Quality (AHRQ) has released its three latest M&M cases from which lessons can be learned to improve patient safety.

#1 – Incorrect documentation of a toddler’s weight as 25 kg instead of 25 lbs, leading to an error in calculating the appropriate antibiotic dosage.   Information focuses on the risks of weight-based dosing, data entry errors and automation complacency with free CME, CEU or trainee certification for taking the quiz.

#2 – how to avoid errors related to the use of unfamiliar devices, highlighting a nurse’s failure to clamp the post-lung transplant patient’s large-bore central line after drawing labs, allowing air to enter the catheter.

#3 –  Inaccurate pathology report which changed diagnosis from an unusual lymphoproliferative disease to adult-onset celiac disease.

Also learn from physicians at Stanford and the Mayo Clinic about the introduction of the modern full-body patient simulator and the use of crew resource management (TeamSTEPPS) training used to improve the delivery of care.

AHRQ Introduces Patient Safety Education & Training Resources Database

A new catalog consisting of 333 patient safety programs has been introduced by AHRQ.   A variety of topics are searchable to assist in locating patient safety education and training.   Each topic is provided with links directly to various educational providers.

Available directly from the AHRQ website, topics can be searched by mode of delivery (such as classroom, self-directed, or web-based), target audience, content, reach, and certification applicability. Topics include TeamSTEPPS, patient satisfaction, culture of safety, handoffs, discharge, and communication (just to name a few).

Take advantage of this capability to quickly locate valuable patient safety education and training resources.   Visit the AHRQ Patient Safety Education and Training Catalog.

Tools Available to Improve Safety of LEP Patients

For patients with limited English proficiency (LEP)   safety can be a challenge.   The Agency for Healthcare   Research and Quality (AHRQ) and TeamSTEPPS now offers a module and guide for “Improving Patient Safety Systems for Patients with Limited English Proficiency: A Hospital Guide.”   Check out available materials including videos, handouts, and train-the-trainer materials.     Additional resources can be found at




AHRQ Offering Free TeamSTEPPS Master Trainer Courses

Free TeamSTEPPS master trainer courses will be offered at six regional training centers throughout the country starting this month – Roslyn Harbor, NY; Durham, NC; New Orleans, LA; Minneapolis, MN;   Denver, CO; Seattle, WA. Many standard trainings are offered as well as four advanced, special topic trainings on simulation, inter-professional education, and teaching TeamSTEPPS to patients and families. These advanced trainings are designed for individuals who already have a strong background in TeamSTEPPS and an interest in the special topic. All materials, training, and enrollment in the online user support network is free!


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.