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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.
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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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, …
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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…
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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…
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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…
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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…
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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…
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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…