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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50887/psn-pdf
    February 12, 2020 - Lessons learned from a systems approach to engaging patients and families in patient safety transformation … Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation … https://psnet.ahrq.gov/issue/lessons-learned-systems-approach-engaging-patients-and-families-patient- … This article describes lessons learned during the six years after a large regional health care system … https://psnet.ahrq.gov/issue/lessons-learned-systems-approach-engaging-patients-and-families-patient-safety-transformation
  2. www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight06.html
    January 01, 2014 - For instance, they can draw on a wider pool of resources and expertise and apply lessons learned from … at least some activities with their partners through regular meetings in which they identify lessons learned … They intentionally delayed Idaho’s implementation so that it could leverage the lessons learned from … “It’s really useful to take the time to work with another State and hear its lessons learned. … Collaborating with these other States has saved us years and years of lessons learned.”
  3. www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/supln-slides.html
    January 01, 2016 - Families in Society Implementing Child Health Measures at the State and Practice-level: Lessons Learned … the CHIPRA Quality Demonstration Grants and the CMS Child Core Set Evaluation Findings and Lessons Learned … Slide 24 Evaluation Findings and Lessons Learned from the CHIPRA Quality Demonstration Grant Program … Slide 55 Lessons Learned Practice performance drives state performance TA and QI tools needed … drives state performance on quality measures Slide 57 Successes/Outcomes Infusion of lessons learned
  4. www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight13.html
    June 01, 2015 - This Highlight focuses on lessons learned from nine States—Alaska, Florida, Idaho, Maine, Massachusetts … Many practices learned how to conduct small tests of change, often using the Plan-Do-Study-Act (PDSA) … When several States (including Alaska, Massachusetts, and West Virginia) learned that practices appreciated … States learned that practice facilitation is most successful when facilitators undergo training in QI … Available at: http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight01.html .
  5. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-alaska-state-snapshot.pdf
    January 01, 2018 - Quality Demonstration Grant Program January 2018 This brief highlights the major strategies, lessons learned … Having learned from the State about the goals and key components of care coordination, all three practices … • Alaska applied the lessons learned from the CHIPRA quality demonstration to other State programs … /demoeval/what-we-learned/highlight11.html https://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned … /highlight11.html https://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight13.html
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865807/psn-pdf
    May 08, 2024 - Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into … Patients’ perspectives on quality and patient safety failures: lessons learned from an inquiry into … https://psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned … https://psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry … https://psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865971/psn-pdf
    May 29, 2024 - Lessons learned from a national hospital antibiotic stewardship implementation project. … Lessons learned from a national hospital antibiotic stewardship implementation project. … https://psnet.ahrq.gov/issue/lessons-learned-national-hospital-antibiotic-stewardship-implementation- … https://psnet.ahrq.gov/issue/lessons-learned-national-hospital-antibiotic-stewardship-implementation-project … https://psnet.ahrq.gov/issue/lessons-learned-national-hospital-antibiotic-stewardship-implementation-project
  8. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-north-carolina-state-snapshot.pdf
    January 01, 2018 - Quality Demonstration Grant Program January 2018 This brief highlights the major strategies, lessons learned … /highlight03.pdf https://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight10.html https … /chipra/demoeval/what-we-learned/highlight11.html http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned … /highlight11.html http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight12.html http … /chipra/demoeval/what-we-learned/highlight13.html http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837000/psn-pdf
    May 06, 2022 - Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication … https://psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath … This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies … https://psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath-fatal-medication … https://psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath-fatal-medication
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74710/psn-pdf
    January 26, 2022 - The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations … The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations … https://psnet.ahrq.gov/issue/evolution-anesthesia-patient-safety-movement-america-lessons-learned-and … https://psnet.ahrq.gov/issue/evolution-anesthesia-patient-safety-movement-america-lessons-learned-and-considerations … https://psnet.ahrq.gov/issue/evolution-anesthesia-patient-safety-movement-america-lessons-learned-and-considerations
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850913/psn-pdf
    June 21, 2023 - Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative … Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative … https://psnet.ahrq.gov/issue/understanding-ultrarare-adverse-events-lessons-learned-twelve-year-review … https://psnet.ahrq.gov/issue/understanding-ultrarare-adverse-events-lessons-learned-twelve-year-review-intraoperative … https://psnet.ahrq.gov/issue/understanding-ultrarare-adverse-events-lessons-learned-twelve-year-review-intraoperative
  12. www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/amplify-impact-webinar.html
    October 01, 2020 - The presentations featured highlights and a discussion of promising practices and key lessons learned
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837069/psn-pdf
    January 01, 2024 - Usability of a human factors-based clinical decision support in the emergency department: lessons learned … Usability of a human factors-based clinical decision support in the emergency department: lessons learned … psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency- department-lessons-learned … psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned … psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853065/psn-pdf
    August 30, 2023 - Exploring the impact of safety culture on incident reporting: lessons learned from machine learning … Exploring the impact of safety culture on incident reporting: lessons learned from machine learning … https://psnet.ahrq.gov/issue/exploring-impact-safety-culture-incident-reporting-lessons-learned-machine … https://psnet.ahrq.gov/issue/exploring-impact-safety-culture-incident-reporting-lessons-learned-machine-learning-analysis … https://psnet.ahrq.gov/issue/exploring-impact-safety-culture-incident-reporting-lessons-learned-machine-learning-analysis
  15. www.ahrq.gov/evidencenow/projects/state/how-to-guide/guide6.html
    August 01, 2024 - This guide aims to help by sharing what has been learned across the Agency for Healthcare Research and … it as needed, apply it in their work, and then in turn share their own insights about what they have learned
  16. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-oregon-state-snapshot.pdf
    January 01, 2018 - Quality Demonstration Grant Program January 2018 This brief highlights the major strategies, lessons learned … Alaska and West Virginia implemented similar projects and met quarterly with Oregon to share lessons learned … https://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight02 … .pdf https://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight02 … .pdf https://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight04
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72848/psn-pdf
    March 17, 2021 - The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned … The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned … psnet.ahrq.gov/issue/development-and-piloting-ambulatory-electronic-health-record-evaluation-tool- lessons-learned … psnet.ahrq.gov/issue/development-and-piloting-ambulatory-electronic-health-record-evaluation-tool-lessons-learned … psnet.ahrq.gov/issue/development-and-piloting-ambulatory-electronic-health-record-evaluation-tool-lessons-learned
  18. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/nashp-webinar-on-quality_measure-use.pdf
    September 21, 2015 - Researcher, Agency for Healthcare Research and Quality • Overview of states’ strategies and lessons learned … jump in with questions or “raise your hand” 4 4 Overview of States’ Strategies and Lessons Learned … plans, providers, public 9 9 Reporting Results to Stakeholders • Lessons learned … ” — North Carolina Practice Manager 14 14 Supporting Provider Improvement • Lessons learned … Project Outcomes Project Outcomes Project Outcomes Lessons Learned Lessons Learned Slide Number
  19. www.ahrq.gov/sites/default/files/wysiwyg/hai/cauti-tools/cauti-icu/preventing-cauti-icu-setting-module_4-speaker-notes.docx
    September 01, 2015 - In Module 1, you learned that hospital-acquired urinary tract infections impact almost 560,000 people … You also learned in Module 1 that very clear, evidence-based guidelines exist about catheter use. … In addition, you learned about the influence of unit culture on practice change and the importance of … You also learned about the power of teachable moments related to catheter use. … SLIDE 4 SAY: In the first three modules, you learned a great deal about catheter use and its impact
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838249/psn-pdf
    October 05, 2022 - Rooting an error review process in just culture: lessons learned. … Rooting an error review process in just culture: lessons learned. … https://psnet.ahrq.gov/issue/rooting-error-review-process-just-culture-lessons-learned Shifting to a … Lessons learned highlight the importance of who performs error follow-up, skills for navigating difficult … https://psnet.ahrq.gov/issue/rooting-error-review-process-just-culture-lessons-learned https://psnet.ahrq.gov