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Showing results for "lessons learned".

2601. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34649/psn-pdf
      June 11, 2014 - On error management: lessons from aviation. June 11, 2014 Helmreich RL. … On error management: lessons from aviation. BMJ . 2000;320(7237):781-785. … https://psnet.ahrq.gov/issue/error-management-lessons-aviation In this perspective, the author draws … Incorporating lessons from aviation, such as focusing on teamwork and communication skills, Helmreich … https://psnet.ahrq.gov/issue/error-management-lessons-aviation https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain

2602. Advancing Patient Safety Through Diagnostic Excellence (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-diagnostic-excellence-webinar.pdf
      June 01, 2025 - Lessons Learned Improved relationships with patients leading to improved experience and safety … Examples of What Teams Learned Recommendations from Participants “Be realistic… it’s very easy … Implementation Roadmap Planning Worksheets Train Your Team Sample Workflow: Be The Expert On You Note Sheet Lessons … Learned Measure Dx:�A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events Foundation … Examples of What Teams Learned Recommendations from Participants Recommendations from Participants

2603. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety | PSNet
      psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
      March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety … What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety … What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety … Framing for learning: lessons in successful technology implementation. … What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety

2604. Promising Areas for Patient Safety Research | PSNet
      psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
      November 02, 2016 - funded 39 patient safety simulation grants.( 8 ) While many of these grants are still in progress, the lessons … learned from successfully completed research projects have been integrated into several AHRQ-sponsored … The time spent, lessons learned, and software developed for localized projects do not transfer easily … Characteristics and lessons learned from practice-based research networks (PBRNs) in the United States … MPH December 1, 2013 Perspective What We've Learned

2605. Final Report, Year 3: CDS Connect (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/cds-connect-year3-final-report-2019.pdf
      January 01, 2019 - Lessons Learned affecting the development of and enhancements to CDS Connect prototype tools: • The … Lessons learned throughout the CDS pilot process: • During the pilot, the CQL Services software failed … Lessons learned affecting CDS artifact development: • The CDS Connect team desired to reuse value sets … These are discussed in greater detail in the Lessons Learned section of the document. … CDS Connect is also contributing to a learning health community by documenting lessons learned across

2606. The San Diego Center for Patient Safety: Creating a Research, Education, and Community Consortium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Pratt.pdf
      March 01, 2004 - patient safety collaborative, delineates some obstacles to long-term success, and presents some of the lessons … we have learned from this endeavor. … we have learned from this endeavor. … Lessons learned Despite its limitations, the SDCPS has made substantial progress. … learned Conclusions Acknowledgments Author affiliations References Figure 1.

2607. Aseptic-Catheter-Insertion-Practices-Inthe Ed Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/aseptic-catheter-insertion-practices-inthe_ED_transcript.docx
      June 02, 2015 - When you think about how you learned to insert a catheter way back in the day, it was probably in a very … You may have first learned on a mannequin. It was all very structured. … There is no resemblance whatsoever to how you learned how to do it. … but to actually talk with staff, engage with staff, also listen to staff and to take from the staff lessons … I hope that there's lessons here that you can use and take back to your facilities.

2608. Aseptic Catheter Insertion Practices in the Emergency Department | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/aseptic-catheter-practices-ed-transcript.html
      December 01, 2017 - When you think about how you learned to insert a catheter way back in the day, it was probably in a very … You may have first learned on a mannequin. It was all very structured. … There is no resemblance whatsoever to how you learned how to do it. … but to actually talk with staff, engage with staff, also listen to staff and to take from the staff lessons … I hope that there's lessons here that you can use and take back to your facilities.

2609. Aseptic Catheter Insertion Practices in the Emergency Department | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/aseptic-catheter-insertion-practices-ed-transcript.html
      December 01, 2017 - When you think about how you learned to insert a catheter way back in the day, it was probably in a very … You may have first learned on a mannequin. It was all very structured. … There is no resemblance whatsoever to how you learned how to do it. … but to actually talk with staff, engage with staff, also listen to staff and to take from the staff lessons … I hope that there's lessons here that you can use and take back to your facilities.

2610. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33639/psn-pdf
      September 01, 2006 - JB: Well, it wasn't just what I learned at NASA. … Everybody learned from a particular person or an institution—which led to, you know, this is the Penn … https://psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md JB: I learned that most people … What lessons are generalizable for the rest of the system? … JB: I think our lessons are uniformly generalizable, I'll say that at the outset.

2611. A New Model of Tracheostomy Care: Closing the Research–Practice Gap (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Clair.pdf
      January 01, 2004 - As we near the end of this pilot project, we have learned many lessons from the adaptation process, … some of which were learned thanks to the strong resources available to us at WRAMC. … Using the lessons that we have learned we hope to adapt more nursing procedures, in a A New Model

2612. VI. Summary and Conclusions | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/hotline/conclusios6.html
      May 01, 2016 - Challenges Identified and Lessons Learned VI. Summary and Conclusions References Appendix A. … We learned, however, that affording patients an opportunity to report their patient safety concerns in … We believe that one of the most important lessons learned from this experience is that it is possible

2613. Training Program Summary: HealthTeamWorks’ Coach University | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/case-studies/health-team-works.html
      August 01, 2014 - The program offers several lessons for others interested in developing and delivering training for practice … includes classroom instruction along with visits to practices to illustrate real-world applications of lessons … Lessons learned HealthTeamWorks leaders identified a number of key lessons learned in the process of … University faculty assess each group of trainees to determine their level of knowledge and skill, and adjust lessons … Moreover, trainees often teach the faculty some new lessons, too.

2614. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49415/psn-pdf
      September 01, 2003 - learned are transferred to real patient care. … facilitate the critical structured debriefing sessions in which performance failures are reviewed and lessons … learned. … Teamwork and collaboration in critical care: lessons from the cockpit. … Anaesthetic simulation and lessons to be learned from aviation.

2615. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45440/psn-pdf
      November 09, 2016 - Safety lessons from the NIH Clinical Center. November 9, 2016 Gandhi TK. … Safety Lessons from the NIH Clinical Center. N Engl J Med. 2016;375(18):1705-1707. … https://psnet.ahrq.gov/issue/safety-lessons-nih-clinical-center System failures can remain undetected … https://psnet.ahrq.gov/issue/safety-lessons-nih-clinical-center https://psnet.ahrq.gov/issue/when-systems-fail

2616. Using-Health-It-To-Support-Qi (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/using-health-it-to-support-qi.pdf
      March 01, 2015 - LEARNED ............................................................................................ … learned and recommendations for primary care practices, health IT developers, and decisionmakers to … To make lessons learned available to more primary care practices and organizations that work with them … Foresight Family Physicians Lessons Learned Our targeted review of published reports and discussions … Learned Recommendations and Conclusions References

2617. Junior doctors' reflections on patient safety. | PSNet
      psnet.ahrq.gov/issue/junior-doctors-reflections-patient-safety
      July 15, 2015 - February 4, 2015 Building a safer foundation: the Lessons Learnt patient safety training … July 6, 2012 Case-based learning for patient safety: the Lessons Learnt program for UK … November 26, 2014 Building a safer foundation: the Lessons Learnt patient safety training

2618. Procedural Mishap: Learning Curve? | PSNet
      psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
      April 28, 2021 - proper angle, controlling thrust, and familiarity with the resistance of the distended peritoneum, are learned … cutting tip trocars, as no major vascular injuries have been reported to date.( 11 ) What are the lessons … Improving continuing medical education for surgical techniques: applying the lessons learned in the first

2619. Program Evaluation - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_8_program-evaluation.pptx
      July 01, 2023 - three domains: LEARNING: assess knowledge, attitudes, and behaviors TRANSFER: assess application of learned … of successful program implementation Reports and publications will be generated to disseminate the lessons … learned 22 Hospital AIM Team Leads SPPC-II SCRIPT And finally, we want to share some key consideration … of successful program implementation Reports and publications will be generated to disseminate the lessons … learned 22 Thank you!

2620. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36421/psn-pdf
      August 05, 2008 - //psnet.ahrq.gov/issue/what-pilots-can-teach-hospitals-about-patient-safety This article discusses lessons … the airline industry has learned about communication, teamwork, and error reporting and how they might