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  1. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/guide-appcusp.pdf
    December 01, 2017 - ........................................................................................ 5 Step 4: Learning … —Safety Team Leader Step 4: Learning From Defects Through Collective Sensemaking Once defects are … We recommend learning from at least one defect a quarter. … We went through the Learning From Defects Through Sensemaking process at our next monthly meeting. … You will find a real-time identification of defects and real-time system of learning.
  2. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/tint.html
    October 01, 2014 - AHRQ News Now Events AHRQ Research Summit on Diagnostic Safety AHRQ Research Summit on Learning … populations, the Agency for Healthcare Research and Quality (AHRQ) developed the Medicaid Care Management Learning … The Learning Network seeks to provide expertise to participating States in four areas critical to ensuring … This Medicaid Care Management Guide reflects the experiences of the initial 13 Learning Network States … In this Guide, we share the experiences of the initial 13 Learning Network States from 2005 through 2007
  3. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/demostates/mdstateataglance.pdf
    March 01, 2012 - one of the 10 grantees, Maryland is working with Georgia and Wyoming in an innovative multi‐State learning … its partner States implemented the project planning tool developed by CHCS as part of its Quality Learning … questions about the implementation and outcomes of their efforts including:  How did the multi‐State learning
  4. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-089-fullreport.pdf
    January 30, 2017 - pediatricians, pediatric neurologists, social workers, school psychologists, family physicians, school-based learning … • School-based Learning Disability Specialists. • A Pediatric Nurse.
  5. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
    July 01, 2018 - Organizational Learning—Continuous Improvement Mistakes have led to positive changes and changes are … Organizational Learning—Continuous Improvement (Strongly Disagree, Disagree, Neither Agree nor Disagree
  6. ce.effectivehealthcare.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/carecoordination-slides.html
    June 01, 2018 - AHRQ News Now Events AHRQ Research Summit on Diagnostic Safety AHRQ Research Summit on Learning
  7. ce.effectivehealthcare.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/womenh-slides.html
    March 01, 2020 - AHRQ News Now Events AHRQ Research Summit on Diagnostic Safety AHRQ Research Summit on Learning
  8. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Galt.pdf
    April 23, 2004 - Workplace conditions Preventive education could be further optimized by learning more from the errors
  9. ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-04/anderson-report.pdf
    January 01, 2024 - Multi-institutional studies were undertaken to measure the learning curve for acquiring wire navigation
  10. ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/pcpaccountability/pcpaccapc.html
    July 01, 2018 - AHRQ News Now Events AHRQ Research Summit on Diagnostic Safety AHRQ Research Summit on Learning
  11. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Campbell.pdf
    January 01, 2003 - An organisation with a memory: report of an expert group on learning from adverse events in the NHS
  12. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Quan_52.pdf
    March 10, 2008 - Learning from others: The diffusion of hospital financing reforms in OECD countries.
  13. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-131-fullreport.pdf
    April 05, 2017 - Medicaid medical directors learning network. Web site; Fact Sheet, 2011.
  14. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
    February 09, 2005 - From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator 395 From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth, Debora A. Paterniti, William Dager, …
  15. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
    December 01, 2004 - Patient Safety Research in Medical Group Practices: Measurement and Data Challenges 51 Patient Safety Research in Medical Group Practices: Measurement and Data Challenges Amy R. Wilson, Bryan E. Dowd, John E. Kralewski Abstract This paper attempts to identify and discuss some of the major challenges to co…
  16. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Tuinen.pdf
    March 01, 2004 - Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes 245 Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes Mark Van Tuinen, Susan Elder, Carolyn Link, Susan Li, John H. Song, Tracey Pritchett Abstract Objectives: This study estimated the validity of 2…
  17. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
    March 15, 2004 - A Study of Adverse Occurrences and Major Functional Impairment Following Surgery 275 A Study of Adverse Occurrences and Major Functional Impairment Following Surgery Mary Rojas, Alan Silver, Christine Llewellyn, Lenora Rances Abstract Objective: The authors sought to ascertain whether adverse occurrences (AOs…
  18. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
    April 22, 2004 - Work System Analysis: The Key to Understanding Health Care Systems 337 Work System Analysis: The Key to Understanding Health Care Systems Ben-Tzion Karsh, Samuel J. Alper Abstract Many articles in the medical literature state that medical errors are the result of systems problems, require systems analyses, a…
  19. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/labordel.pdf
    March 18, 2014 - TeamSTEPPS Speciality Scenarios, Labor & Delivery TeamSTEPPS 2.0 Specialty Scenarios - 103 Specialty Scenarios L&D Specialty Scenarios - 104 TeamSTEPPS 2.0 Specialty Scenarios L&D Scenario 85 Appropriate for: L&D Setting: Hospital Sue Jones a 28-year-old G1 P0 at term is undergoing an…
  20. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Alexander_10.pdf
    January 20, 2008 - Measuring IT Sophistication in Nursing Homes Measuring IT Sophistication in Nursing Homes Gregory L. Alexander, PhD, RN; Dick Madsen, PhD; Stephanie Herrick; Brady Russell Abstract Objective: Little activity has occurred in nursing home (information technology) IT adoption. The purpose of this study was to de…

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