Results

Total Results: 1,419 records

Showing results for "lessons learned".

1001. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
      January 01, 2019 - . • Scientifically rooted in more than 20 years of research and lessons from the application of teamwork … The key lessons for hospitals implementing the CANDOR process in their institutions include how to: … This website provides links to the lessons from the phases and results from the program.

1002. AHRQ EvidenceNOW: Building State Capacity: Interim Evaluation Report I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/en-bsc-interim-report-1.pdf
      January 31, 2024 - To support rural primary care practices and build on lessons learned from AHRQ’s prior EvidenceNOW initiatives … learned. … learned so far … learned. … learned so far

1003. Appendix C: Alternate Care Facility Questionnaire | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/shuttered/acfselection/appendixc.html
      July 01, 2018 - What lessons did you learn with regards to integrating non-health care provider volunteers into the operation … Were there any lessons learned with regards to doing so?       ___  Yes   ___  No      12a.

1004. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions7.html
      June 01, 2023 - Handoff strategies in settings with high consequences for failure: lessons for health care operations … Usability of a human factors-based clinical decision support in the emergency department: lessons learned

1005. National Pcep Meeting White Paper (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/national_pcep_meeting_white_paper.docx
      May 05, 2014 - funding was coming to a close, the four grantees explored strategies for bringing together what had been learned … Infrastructure for large-scale quality-improvement projects: early lessons from North Carolina Improving … The North Carolina Healthcare Quality Alliance: lessons in aligning quality improvement strategies statewide

1006. CUSP: A Framework for Success (Slide Presentation) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/framework-slides/slides.html
      October 01, 2014 - Learn from one defect per quarter; share or post lessons.

1007. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
      July 18, 2008 - In aviation, the crew debriefs after every flight so as to incorporate lessons learned in real time. … Diagnosing diagnosis errors: Lessons from a multi-institutional collaborative project. … Handoff strategies in settings with high consequences for failure: Lessons for health care operations

1008. What Exactly Is Patient Safety? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
      July 02, 2008 - Commentators asserted that the more error-related information was shared, the better lessons could be … These and other developments produced a readiness for looking at what might be learned and adapted from … espouses continuous cycles of learning, reporting of adverse events or near misses, dissemination of lessons … learned, and the establishment of cultures that are trusted to not cast unfair blame. … What have we learned? JAMA 2005; 293: 2384-2390. 6. Leape LL, Bates DW, Cullen DJ, et al.

1009. TeamSTEPPS® Diagnosis Improvement: Module 6 Mutual Support - Facilitator’s Notes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module6-presenters-notes.pdf
      January 10, 2022 - Frame problems in terms of personal experience and lessons learned. • Choose the location. … In this module, participants learned that: • Mutual support fosters team adaptability, mutual trust,

1010. Module 6: Mutual Support
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module6-mutual-support.pptx
      January 10, 2022 - Frame problems in terms of personal experience and lessons learned. Choose the location. … In this module, participants learned that: Mutual support fosters team adaptability, mutual trust, and

1011. Person-Centered Care Planning for Persons With Multiple Chronic Conditions: Summit Summary Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/mcc/pccp4p/pccp4p-summitsummary.pdf
      September 01, 2025 - Share lessons learned from TEP, PR, and LC sessions as a foundation for identifying opportunities for … The Summit shared lessons learned from the prior year’s work conducted by three expert panel groups … Objectives 1) Share lessons learned from Roundtable and Learning Collaborative sessions as a foundation

1012. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
      June 30, 2004 - selected reports for analysis, the results of both our quantitative and qualitative analyses, and what we learned … that collect information about medical errors so that practitioners can learn from them and apply lessons … learned to promote patient safety. … Conclusions Our mixed methods approach allowed us to efficiently and effectively extract patient safety lessons

1013. A4A Combo Psi Casestudy (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a4a_combo_psi_casestudy.pdf
      June 02, 2025 - Robinson has several key lessons to share with new users to facilitate their quality improvement journey

1014. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
      August 01, 2022 - project culminated in an SDM train-the-trainer toolkit that integrates the processes developed and lessons … learned. … The researchers also learned through the project that the taxonomy used to classify errors could be streamlined … Implementing near-miss reporting and improvement tracking in primary care practices: Lessons learned. … There will be efforts to use what was learned to improve the claims reporting system, further the development

1015. Small and Rural and Critical Access Hospitals (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
      April 01, 2013 - I know we’ve had several hospitals do that, and they’ve learned it hasn’t been an implementation issue … And then once you’ve indentified a defect, then you share and post lessons that you’ve learned. … So even within your hospital, if you’ve piloted something on one unit, you want to share the lessons … learned throughout the hospital. … I think from Denise and Lorna we learned about the fundamentals of CUSP.

1016. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
      January 01, 2004 - An important lesson learned from this near miss was that a lack of a reliable research-participant tracking … Based on lessons learned from this debriefing, a clinical research sign-out system is being developed … Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.

1017. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
      May 25, 2023 - OSHA,PSOs) • Alliance providing a central repository of lessons learned, best practices, harm events

1018. Breaking Down Barriers to Aseptic Catheter Insertion (May 12, 2015) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-transcript.html
      December 01, 2017 - For those of you in the audience who are nurses, if you think about your early nursing days, when you learned … Maybe that's just one of those things that I learned in school but gee, in practice, nobody seems to … Some of the lessons learned is that the basics do need to be assessed and addressed. … As was mentioned before, most of the nurses have learned and performed this skill in a very controlled … Also, a lesson learned for us is that in both instances, the industry was very helpful in improving the

1019. Breaking-Down-Barriers-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/breaking-down-barriers-transcript.docx
      May 12, 2015 - For those of you in the audience who are nurses, if you think about your early nursing days, when you learned … Maybe that's just one of those things that I learned in school but gee, in practice, nobody seems to … Some of the lessons learned is that the basics do need to be assessed and addressed. … As was mentioned before, most of the nurses have learned and performed this skill in a very controlled … Also, a lesson learned for us is that in both instances, the industry was very helpful in improving the

1020. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/4es-early-mobility-facguide.docx
      January 01, 2017 - Slide 27 Summary ASK: What have we learned today about the Four Es of early mobility?