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Showing results for "learned".

6481. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology-references.html
      April 01, 2025 - Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

6482. Improving the Delivery of Health Services at the Health Systems Level - Emerging Research | Digital Healthcare Research
      digital.ahrq.gov/2020-year-review/research-summary/improving-delivery-health-services-health-systems-level-emerging-research
      January 01, 2020 - across different healthcare systems and technologies (e.g., different EHRs) and disseminate lessons learned

6483. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33848/psn-pdf
      December 01, 2017 - We should have learned from experience never to do this.… The [other] guilty party is the chief resident

6484. Mark My Limb | PSNet
      psnet.ahrq.gov/web-mm/mark-my-limb
      February 10, 2015 - Lessons learned: wrong site surgery.

6485. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
      February 01, 2014 - Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

6486. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33829/psn-pdf
      March 01, 2017 - s desire for more data was balanced with the intent to act on what they had already learned.

6487. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49460/psn-pdf
      September 01, 2004 - https://psnet.ahrq.gov/web-mm/security-lapse The Case A medical student learned that the hospital's

6488. Addressing Unhealthy Alcohol Use: Resources From AHRQ | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/954.html
      April 01, 2025 - Addressing Unhealthy Alcohol Use: Resources From AHRQ Issue Number 954 AHRQ News Now is a weekly newsletter that highlights agency research and program activities. April 22, 2025 AHRQ Stats: Average Annual Spending on Adult Opioid Prescriptions Between 2021 and 2022, average annual total outpatient pres…

6489. Special Considerations for Measurement of Diagnostic Safety (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2b.html
      June 01, 2020 - Operational Measurement of Diagnostic Safety: State of the Science Special Considerations for Measurement of Diagnostic Safety (continued) Previous Page Next Page Table of Contents Operational Measurement of Diagnostic Safety: State of the Science Introduction Special Considerations for Measurem…

6490. Presentation: Tools for Sustainability: Premortem and Scorecard
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-slides.pptx
      January 01, 2017 - Presentation: Tools for Sustainability: Premortem and Scorecard Tools for Sustainability: Premortem and Scorecard AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-39-EF January 2017 Sustainability Tools ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Ob…

6491. Diagnostic Safety Research (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/DiagnosticSafety-flier.pdf
      November 01, 2024 - Diagnostic Safety Research 1 Diagnostic Safety Research at the Agency for Healthcare Research and Quality Diagnostic Error Diagnostic error is a significant and underrecognized threat to patient safety. Diagnostic errors are common, consequential, and costly and contribute to avoidable suffering and prevent…

6492. Improving Diagnosis in Emergency and Acute Care: A Learning Laboratory (IDEA-LL) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/resources/learning-lab/idea-ll-long-desc.html
      August 01, 2025 - Improving Diagnosis in Emergency and Acute Care: A Learning Laboratory (IDEA-LL) Principal Investigator:  Prashant Mahajan, M.D., M.P.H., M.B.A., University of Michigan, Ann Arbor, MI Co-PIs:  Kalyan Pasupathy, Ph.D., University of Illinois, Chicago, IL; Hardeep Singh, M.D., M.P.H., Department of Veterans Affai…

6493. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33825/psn-pdf
      January 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis Annual Perspective 2016 Introduction Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…

6494. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60547/psn-pdf
      May 28, 2020 - The Role of the FDA in Ensuring Device Safety May 28, 2020 Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety Introduction The Food and Drug Administration (FDA) plays a critical role in ensuring the …

6495. CUSP Psychological Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/cusp-psychological-safety.html
      November 01, 2024 - MRSA Prevention Toolkit: ICUs & Non-ICUs CUSP Psychological Safety Previous Page Next Page Table of Contents MRSA Prevention Toolkit: ICUs & Non-ICUs The Four Key Strategies of MRSA Prevention The Importance of MRSA Prevention Decolonization Tools & Resources for Decolonization Tools & Res…

6496. CAHPS® Moving Forward: Innovations in Tools and Research Webcast (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-moving-forward-ginsberg-slides.pdf
      October 12, 2017 - CAHPS® Moving Forward: Innovations in Tools and Research Webcast AHRQ’s CAHPS® Program Caren Ginsberg, PhD Director, CAHPS Division Center for Quality Improvement & Patient Safety October 12, 2017 www.ahrq.gov/cahps AHRQ: An R & D Agency • AHRQ: • Advances science • Creates knowledge from data • Creates to…

6497. AHRQ Quality Indicators v2025 Software Release and Webinar | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/qi-webinar.html
      August 01, 2025 - AHRQ Quality Indicators v2025 Software Release and Webinar AHRQ is pleased to announce the AHRQ Quality Indicators v2025 software release (August 29) and Webinar (September 16).   The AHRQ Quality Indicators (QI) v2025 Software will be available for download from the AHRQ QI website at: https://qualityindicato…

6498. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-checklist.docx
      January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle AHRQ Safety Program for Mechanically Ventilated Patients Physician Champion Checklist Improving Care for Mechanically Ventilated Patients 1. Serve as a clinical role model for evidence-based practices 2. Ensure physicians are educated about project goals and …

6499. Teamwork and Communication for Perinatal Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork.html
      July 01, 2023 - Teamwork and Communication for Perinatal Safety Toolkit for Improving Perinatal Safety This pillar presents six concepts of the Comprehensive Unit-based Safety Program (CUSP) to help teams understand CUSP and its application to perinatal safety. Learn About CUSP for Perinatal Safety Slide Presentation (…

6500. Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams.html
      July 01, 2023 - Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety Next Page Table of Contents Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety Introduction The Patient-Clinician Dyad The Patient-Artificial I…