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ahrqpubs.ahrq.gov/talkingquality/translate/web/pathways/measures.html
October 01, 2015 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning
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ahrqpubs.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-slides.html
December 01, 2017 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning … Slide 2
Learning Objectives
Discuss results of a study that identified common barriers to the use … Slide 40
Learning & Sustaining
Lessons Learned:
Basics do need to be assessed and addressed
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ahrqpubs.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/index.html
December 01, 2017 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning
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ahrqpubs.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/index.html
December 01, 2017 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning
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ahrqpubs.ahrq.gov/research/findings/final-reports/index.html?page=8
September 01, 2005 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning … Number: U18 HS 11114 Topic(s): Patient Safety Tools Publication Date: August 2004
Creating Learning
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ahrqpubs.ahrq.gov/patient-safety/reports/national-academy-medicine.html
February 01, 2018 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning … report looks at the impact of medical residents’ workloads and duty hours on patient safety and the learning
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medoffice-resourcelist.pdf
April 01, 2023 - Organizational Learning ............................................................................ … It is
primarily targeted to individual licensed clinicians for learning and improvement purposes. … Organizational Learning
1. Root Cause Analysis
a. … Developing a Reporting Culture: Learning From Close Calls and Hazardous Conditions
3. … Organizational Learning
1. Root Cause Analysis
2.
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule4.pptx
March 10, 2006 - So these really are an excellent learning opportunity for the team members. … where people can fairly and honestly talk about mistakes that might have been done, and see this as a learning … effectively resolve the conflict, it can assure that the patient gets good care, but it also provides learning … And this provides, again, an opportunity for learning and for discussion about what's most effective, … To complete this module and receive accreditation, you must return to the TeamSTEPPS Learning Management
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ahrqpubs.ahrq.gov/patient-safety/settings/hospital/resource/pressure-injury/index.html
October 01, 2017 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning … Webinar Content
Training Webinars Learning Network Webinars Video
Related AHRQ Resources
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ahrqpubs.ahrq.gov/hai/cusp/modules/download/index.html
December 01, 2012 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning
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ahrqpubs.ahrq.gov/hai/tools/surgery/modules/index.html
December 01, 2017 - AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/safemed_facguide.docx
May 01, 2017 - The key safety elements related to learning from defects for oxytocin administration include—
Debriefing … improvement from informal and formal analysis with staff to achieve transparency and organizational learning … The key safety elements of learning from defects are the same as for oxytocin:
Debriefing near misses … the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4b_combo_psi05-foreignbody-bestpractices.pdf
November 01, 2012 - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/Downloads/wPOA-Fact-Sheet.pdf … _13_FINAL.pdf
http://www.nothingleftbehind.org/
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN … /MLNProducts/Downloads/wPOA-Fact-Sheet.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
January 01, 2012 - for Medicare & Medicaid Services; October
2012. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN … national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN … /MLNProducts/Downloads/wPOA-Fact-Sheet.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teach-back-role-play-final508.pdf
April 05, 2018 - Using the discussion prompts (page 3), engage the training group in a learning
discussion on what went … Using the discussion prompts (page 3), engage the training group in a learning
discussion on what went … Using the discussion prompts (page 3), engage the training group in a learning
discussion on what went
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-roleplay-final508.pdf
April 03, 2018 - Using the discussion prompts (page 3), engage the training group in a learning
discussion on what went … Using the discussion prompts (page 3), engage the training group in a learning
discussion on what went … Using the discussion prompts (page 3), engage the training group in a learning
discussion on what went
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ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
January 01, 2014 - death.
44% of adverse events were preventable.
5
Following Harm: Not Always Transparent, Not Always Learning … Barriers
Fears
Litigation
Data Bank
Shame, blame
Reputation
Lack of skills
Lack of process
Benefits
Learning … Benefits from an open and transparent culture include:
Organizational learning that leads to improvements … of CANDOR
Module 1
27
The culture of the CANDOR process provides the opportunity for continuous learning … Organizational learning and sustainment—The organization takes what they have learned from the event
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ahrqpubs.ahrq.gov/cpi/index.html
AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning
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ahrqpubs.ahrq.gov/topics/u.html
AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning
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ahrqpubs.ahrq.gov/topics/n.html
AHRQ News Now
Events
AHRQ Research Summit on Diagnostic Safety
AHRQ Research Summit on Learning