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digital.ahrq.gov/sites/default/files/docs/page/CDS_challenges_and_barriers.pdf
July 30, 2007 - AND FUTURE WORK ....................................................................... 22
Lessons Learned … • Establish lessons learned for CDS implementation relevant to the health information
technology … As GLIDES staff learned, the project team needed to consider issues with the development of
rules for … Lessons Learned
The experience to date of these two contractors provides lessons that are particularly … Lessons Learned
The experience to date of these two contractors provides lessons that are particularly
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effectivehealthcare.ahrq.gov/sites/default/files/lessons-transcript.pdf
October 08, 2025 - I don’t think that we want to suggest that everything that we’ve
learned from CBPR is enough. … Clearly we’ve learned how to do CBPR for other types of
questions and my guess is that the methods will … In an urban environment we learned very
loud and clear that in West Baltimore every neighborhood had … One alternative is something that we’ve learned from the safety net hospital, and the research
nurse … Thank you so much and we hope you learned something today.
Structure Bookmarks
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www.ahrq.gov/hai/cusp/videos/01a-intro/index.html
June 01, 2018 - Introduction
The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit.
Learn About CUSP [10 min. 10 sec.]
YouTube…
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digital.ahrq.gov/principal-investigator/butler-jorie-m
January 01, 2023 - Butler, Jorie M.
An Age-Friendly Learning Healthcare System: A Transformative Digital Solution for Geriatrics Clinics
Description
The study will create and implement digital tools using the SMART on FHIR framework to support Age-Friendly care in clinical practice and instituti…
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psnet.ahrq.gov/node/38247/psn-pdf
June 27, 2018 - Debriefing for patient safety.
June 27, 2018
Turner SH, Kurtz WD. Patient Saf Qual Healthc. November/December 2008:5:42-44,46.
https://psnet.ahrq.gov/issue/debriefing-patient-safety
This article provides guidelines for effective clinical debriefings and suggests how to position these
conversations as learning oppo…
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psnet.ahrq.gov/node/37250/psn-pdf
October 10, 2007 - Why worry about near misses?
October 10, 2007
Marella WM.
https://psnet.ahrq.gov/issue/why-worry-about-near-misses
The author describes the collection and management of information on near misses as well as using such
data to support learning opportunities for hospital staffs.
https://psnet.ahrq.gov/issue/why-wor…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/102-how-to-integrate-cusp-approach-periop.pptx
April 01, 2025 - lasting change in the clinical area
CUSP happens WITH others, not BY others
Improvements that are learned
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www.ahrq.gov/hai/tools/mvp/modules/cusp/patient-family-care-slides.html
March 01, 2017 - 12: Patient-Centered Care
Patient-Centered Care
Slide 13: Empathy Is Important
"I have learned
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Lessons learned from adverse events could help improve future patient safety.
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - as an integral component of quality improvement.( 10 ) The father might have been less angry had he learned
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
December 01, 2003 - The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents
387
The Incident Decision Tree: Guidelines for
Action Following Patient Safety Incidents
Sandra Meadows, Karen Baker, Jeremy Butler
Abstract
The National Patient Safety Agency has developed the Incident Decision Tree to
hel…
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psnet.ahrq.gov/submit-case
November 03, 2025 - The Submit a Case Process
PSNet’s Submit a Case feature allows health care professionals to submit de-identified cases that feature patient safety and health care quality issues to PSNet’s WebM&M educational journal. Watch the video below to learn more about the Submit a Case process.
Submit Your Case
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Mitchell.pdf
March 31, 2004 - Creating a Curriculum for Training Health Profession Faculty Leaders
299
Creating a Curriculum for Training
Health Profession Faculty Leaders
Pamela H. Mitchell, Lynne S. Robins, Douglas Schaad
Abstract
Objectives: An interprofessional, collaborative group of educators, patient safety
officers, and Federal …
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www.ahrq.gov/nursing-home/resources/post-vaccination-practices.html
August 01, 2022 - Post-Vaccination Practices series
Resource: Post-Vaccination Practices series
This series of two learning modules features strategies to help nursing home teams minimize infection risk in their facility.
Source: AHRQ
Topic(s): Vaccination; Infection Control & Prevention
Audience(s): Managers, Clinic…
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digital.ahrq.gov/topics-az/m
January 01, 2023 - Topics A-Z
A
B
C
D
E
G
H
I
K
L
M
N
P
Q
R
S
T
U
V
W
Machine Learning
Meaningful Use
Medication
Medication Adherence
Medication Errors
Medicat…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
September 01, 2021 - Apply lessons learned from trends and
improvements in morbidity and mortality
due to various comorbidities
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
April 01, 2023 - Ariadne Labs has developed a framework for WHO Safe Surgery Checklist implementation based
on lessons learned
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/build-patient-understanding-setbacks-and-how-deal-them
June 01, 2022 - An official website of the Department of Health & Human Services
Search All AHRQ Sites
Careers
Contact Us
Español
FAQs
Email Updates
The Academy
Integrating Behavioral Health & Primary Care
Expand Navi…
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/enhancing-care-heart-failure-patients.pdf
June 02, 2025 - TAKEheart Affinity Group:
Enhancing Care for Heart Failure
Patients in Cardiac Rehabilitation
H i c h a m S k a l i , M D , M S c
S t e v e n K e t e y i a n , P h D
D a n i e l F o r m a n , M D
M i c h e l l e Yo u n g , M S N , A N P - B C
N o v e m b e r 2 , 2 0 2 1
Welcome and Background for Tod…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfepc-fullguide-appc-final508.pdf
June 02, 2025 - The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families | 26
Appendix C – Teach-Back Implementation Guidance
To help you plan and design your Teach-Back implementation, a Quick…