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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/huddles-pdsa-form.html
June 01, 2017 - Act : PLAN for our next cycle based on what we learned. … What decisions do we make based on what we learned?
… Act : PLAN for our next cycle based on what we learned. … What decisions do we make based on what we learned?
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/qtag-presentation.pdf
September 01, 2015 - initiatives
- Improving service delivery
Provide information about
- What states did
- What we learned … 8
Findings: Using core quality measures for
State-based QI initiatives
Some of what we learned … participation, hiring practice-level staff
10
Findings: Service delivery models
Some of what we learned … research findings)
18 brief State summaries (description of what each state did
and what they learned
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psnet.ahrq.gov/issue/participating-multisite-study-exploring-operational-failures-encountered-frontline-nurses
July 05, 2017 - Participating in a multisite study exploring operational failures encountered by frontline nurses: lessons learned … Participating in a Multisite Study Exploring Operational Failures Encountered by Frontline Nurses: Lessons Learned … Participating in a Multisite Study Exploring Operational Failures Encountered by Frontline Nurses: Lessons Learned
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psnet.ahrq.gov/issue/lessons-learned-use-event-reporting-nurses-improve-patient-safety-and-quality
May 19, 2013 - Study
Lessons learned: use of event reporting by nurses to improve patient safety … Lessons learned: use of event reporting by nurses to improve patient safety and quality. … Lessons learned: use of event reporting by nurses to improve patient safety and quality.
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psnet.ahrq.gov/issue/lessons-learned-basic-evidence-based-advice-preventing-medication-errors-children
December 22, 2008 - Commentary
Lessons learned: basic evidence-based advice for preventing medication … Lessons learned: basic evidence-based advice for preventing medication errors in children. … Lessons learned: basic evidence-based advice for preventing medication errors in children.
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psnet.ahrq.gov/issue/lessons-learned-implementation-computerized-provider-order-entry-5-community-hospitals
December 31, 2014 - Study
Lessons learned from implementation of computerized provider order entry in … Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a … Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a
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psnet.ahrq.gov/issue/improving-safety-culture-results-rhode-island-icus-lessons-learned-development-action
September 17, 2010 - Study
Improving safety culture results in Rhode Island ICUs: lessons learned from … Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented … Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented
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psnet.ahrq.gov/issue/lessons-learned-implementation-computerized-application-pending-tests-hospital-discharge
March 04, 2015 - Study
Lessons learned from implementation of a computerized application for pending … Lessons learned from implementation of a computerized application for pending tests at hospital discharge … Lessons learned from implementation of a computerized application for pending tests at hospital discharge
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psnet.ahrq.gov/issue/adopting-electronic-medical-records-primary-care-lessons-learned-health-information-systems
January 07, 2015 - Review
Adopting electronic medical records in primary care: lessons learned from … Adopting electronic medical records in primary care: lessons learned from health information systems … Adopting electronic medical records in primary care: lessons learned from health information systems
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psnet.ahrq.gov/issue/intravenous-medication-safety-and-smart-infusion-systems-lessons-learned-and-future
January 09, 2008 - Commentary
Intravenous medication safety and smart infusion systems: lessons learned … Intravenous medication safety and smart infusion systems: lessons learned and future opportunities. … Intravenous medication safety and smart infusion systems: lessons learned and future opportunities.
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psnet.ahrq.gov/issue/hospitalists-emerging-leaders-patient-safety-lessons-learned-and-future-directions
July 14, 2010 - Study
Hospitalists as Emerging Leaders in Patient Safety: lessons learned and future … Hospitalists as emerging leaders in patient safety: lessons learned and future directions. … Hospitalists as emerging leaders in patient safety: lessons learned and future directions.
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psnet.ahrq.gov/issue/implementing-hospital-based-communication-and-resolution-programs-lessons-learned-new-york
September 01, 2018 - Study
Implementing hospital-based communication-and-resolution programs: lessons learned … Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. … Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.
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psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
February 26, 2025 - We spoke with him about lessons learned over the years regarding event reporting and his insights regarding … What are the lessons learned over the years regarding event reporting? … The physicians learned this is a great number to call because you're going to get all that support. … RW : What have we learned about teaching health care professionals how to have these conversations and … That is a big lesson we've learned.
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psnet.ahrq.gov/issue/diversion-threat-patient-safety-adopting-best-practices
April 20, 2022 - February 23, 2022
Lessons Learned about Human Fallibility, System Design, and Justice … October 5, 2022
Lessons Learned about Human Fallibility, System Design, and Justice in … June 24, 2020
Medication Safety During the COVID-19 Pandemic: What Have We Learned in
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/qde-mmd-webinar-slides.html
January 01, 2016 - Overview of states' strategies and lessons learned
Joe Zickafoose, M.D., M.S., Senior Researcher, … health plans, providers, the public
Slide 8
Reporting Results to Stakeholders
Lessons learned … care organizations to meet quality benchmarks
Slide 10
Aligning QI Priorities
Lessons learned … require accurate documentation
Slide 13
Supporting Provider Improvement
Lessons learned … Slide 36
Lessons Learned
Providers pursued a range of tactics to improve quality of care
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/zero_clabsis-slides/Sustaining-Zero-CLABSIs-May-8-2012-508.ppt
January 01, 2012 - defects they identified
Shared how they implemented the Learning from Defects process
Shared what they learned … Identified Defect Identified Defect Identified Defect Identified Defect Identified Defect Identified Defect
Learned … from Defect Learned from Defect Learned from Defect Learned from Defect Learned from Defect Learned … Exec Rounds Identified Defect Learned from Defect Shared findings
Q3 2010 n=98 52% 22% 17% 16%
Q4 2010
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psnet.ahrq.gov/node/837146/psn-pdf
May 18, 2022 - psnet.ahrq.gov/issue/transition-new-electronic-health-record-and-pediatric-medication-safety-lessons-learned … https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/co-nm-specialinnovation.html
August 01, 2015 - CHIPRA quality demonstration is available at http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned
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cds.ahrq.gov/sites/default/files/workgroups/143366/CDS_Connect_WG_April_2022_Presentation.pdf
January 01, 2022 - 5
“One More Step” Campaign
Objective
• During this CDS Connect project year, gather lessons
learned … lifecycle on how standards/
methods/best practices can better support
patient involvement
Lessons Learned … • Lessons learned:
► Earlier involvement; better planning; role clarity; positive constructive feedback … clinical manager; QM leader, EMR implementation consultant; and Board of Governors
of PCORI
• Lessons learned … new FAQ entry on CDS Connect
► Include reference in Repository User Guide
• Invite and share lessons learned
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/vu_physician_patient_harms.pdf
June 02, 2025 - From our one-on-one physician interviews, we learned that:
Physicians consider several factors when … -Lead Physician
From our clinician surveys, we learned that:
90% reported that clinical evidence … From our case studies interviews with primary care physicians and their patients, we learned that: