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Showing results for "lessons learned".

1161. System Redesign Responses to Challenges in Safety-Net Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/system/systemredesignsafetynet/systemredesign.pdf
      June 01, 2015 - As we learned, some of their experiences have been positive, but the systems also occasionally struggle … Staff learned that improvement work does not need to be perfect; small changes can make a big difference … Green Belts returning to the organization did not have the skills to deploy what they had learned and … Instead, different systems provide lessons on different dimensions: both the practices that are working … While these cases are only illustrative, we believe they offer important lessons about redesign and

1162. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
      December 01, 2003 - The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents 387 The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents Sandra Meadows, Karen Baker, Jeremy Butler Abstract The National Patient Safety Agency has developed the Incident Decision Tree to hel…

1163. Implementing U.S. Preventive Services Task Force (USPSTF) Recommendations into Health Professions Education (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cpi/centers/ockt/kt/tools/impuspstf/impuspstf.pdf
      September 21, 2010 - Implementing U.S. Preventive Services Task Force (USPSTF) Recommendations into Health Professions Education TECHNICAL ASSISTANCE DOCUMENT IMPLEMENTING U.S. PREVENTIVE SERVICES TASK FORCE (USPSTF) RECOMMENDATIONS INTO HEALTH PROFESSIONS EDUCATION September 21…

1164. National Opportunity To Improve Infection Control in ESRD (NOTICE) Phase Two Final Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/finalreportphase2.pdf
      September 29, 2014 - Checklist and Change Package Use in the Community ..................................................... 38 Lessons … Learned ............................................................................................ … Lessons Learned The lessons learned from the NOTICE project are many and vary in topic and significance … HRET has learned from its experience in previous clinically focused projects (On the CUSP: Stop CLABSI … Lessons learned regarding the production of videos include the need for clearly defined goals and objectives

1165. Final Progress Report: Partnering With Patients To Find Adverse Events (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/weingart2-report.pdf
      January 01, 2024 - In addition, the lessons from inpatient care appear to hold in the ambulatory setting. … Lessons from a patient partnership intervention to prevent adverse drug events.

1166. Pediatric Patient Safety Consortium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA204-Materials_XIII.pdf
      August 25, 2014 - Implementing developmental screening and referrals: lessons learned from a national project. … questioning indicates the little girl is already reading and writing postcards to relatives, but has not learned … Implementing developmental screening and referrals: lessons learned from a national project. … Implementing developmental screening and referrals: lessons learned from a national project. … Implementing developmental screening and referrals: lessons learned from a national project.

1167. TeamSTEPPS® Diagnosis Improvement: Module 7: Putting It All Together (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module7-presenters-notes.pdf
      January 01, 2008 - Considering when, where, and how use of the TeamSTEPPS tools and lessons from this course may have resulted … In this module, participants learned that: • Diagnostic error is a patient safety issue and applications

1168. Module 7: Putting It All Together
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module7-all-together.pptx
      January 01, 2008 - Considering when, where, and how use of the TeamSTEPPS tools and lessons from this course may have resulted … In this module, participants learned that: Diagnostic error is a patient safety issue and applications

1169. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
      September 01, 2021 - Apply lessons learned from trends and improvements in morbidity and mortality due to various comorbidities

1170. Estimating the Costs of Primary Care Transformation: A Practical Guide and Synthesis Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/estimating-costs-primary-care-transformation.pdf
      July 31, 2015 - learned from the 15 AHRQ Estimating Costs grants. … learned. … learned for the field. … learned from the 15 AHRQ Estimating Costs grantees were used to develop the Practical Guide at the … Contrasting trajectories of change in primary care clinics: lessons from New Orleans safety net.

1171. Final Progress Report: Improve Safety, Quality, and Efficiency in Radiotherapy with Automated HIT System (pdf file)
      www.ahrq.gov/sites/default/files/2024-04/yang-report.pdf
      January 01, 2024 - both safety and quality control have been improving due to workflow improvements according to the lessons … learned from previous incidents and following published recommendations and guidelines.

1172. Strategy 4: IDEA Discharge Planning (Implementation Handbook) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
      April 01, 2011 - This guide integrates what hospitals that participated in Transforming Care at the Bedside learned as … Identify lessons learned from the single-unit pilot implementation, refine your approach, and then spread … Reducing hospital readmissions: lessons from top-performing hospitals.

1173. Slide 1 (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-engaging-clinicians-051413.ppt
      January 01, 2013 - Slide 1 Preventing CAUTI: Engaging Clinicians and Senior Leadership to Implement Change * Sanjay Saint, MD, MPH M. Todd Greene, MPH, PhD University of Michigan Medical School Ann Arbor VA Medical Center Learning Objectives Describe the methods to engage clinicians in CAUTI prevention Describe methods to engage l…

1174. 105-What-Are-The-4-Es-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/105-what-are-the-4-es-notes.docx
      April 01, 2025 - Lessons learned should be shared.

1175. Strategy 6F: On-Demand Advice, Diagnosis, and Treatment for Minor Health Conditions | Agency for Healthcare Research and Quality
      www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/strategy6f-ondemand.html
      April 01, 2023 - Malpractice claims in Swedish telenursing: lessons learned from interviews with telenurses and managers

1176. Final Grant Report: Using Military & Aviation Simulation Experience to Improve Rural Obstetric Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/guise2-report.pdf
      January 01, 2024 - • The error protection mechanisms that the teams had learned were even evident in a completely new … skills, including consistent use of team language, were evident on the second visit, indicating that learned … training program designed to improve clinical teamwork and safety in obstetrics, the toolkit, and lessons … learned.

1177. Final Progress Report: Mentored Implementation of I-PASS for Better Handoffs and Safer Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/landrigan-report.pdf
      January 01, 2024 - Educational Conference 2016 Strategies for Implementing a Successful Handoff Program for Hospitalists: Lessons … learned from the SHM-IPASS Mentored Implementation Program Society for Hospital Medicine Annual … Aires, Argentina 2017 Strategies for Implementing a Successful Handoff Program for Hospitalists: Lessons … learned from the SHM-IPASS Mentored Implementation Program Cohort 2 Society for Hospital Medicine

1178. Final Report: Embracing the PBRN Model To Improve the Medication Use Process (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/lipowski-report.pdf
      January 01, 2024 - Results: Key Strategies for Establishing a Pharmacy PBRN Key strategies Meeting evaluation Lessons … learned Outgrowths of the conference VI. … Lessons Learned The participant evaluations were quite positive, as evidenced by the response to the

1179. AHRQ_HHS Brand_Color (doc file)
      www.ahrq.gov/sites/default/files/publications/files/execsumm-lean-redesign.docx
      March 01, 2017 - Develop and disseminate knowledge and lessons learned about what factors affect the scale-up and sustainability

1180. A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
      June 11, 2003 - ultimate goal was to uncover real and potential problems at an earlier stage so that appropriate lessons … can be learned and corrective actions taken.