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Showing results for "lessons learned".

2621. Spreadnotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
      June 02, 2025 - Essentially, knowledge management and knowledge transfer explore taking lessons learned in one unit and … transferring those lessons to other units to create better ideas that fit with the social system. … significantly—should wait to put the new process in place so they can benefit from the data collected and the lessons … learned by the units that adopted the process earlier..

2622. 4. Selecting and Delivering Services To Support Quality Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/projects/state/how-to-guide/guide4.html
      August 01, 2024 - to learn from one another; build peer support and community; and share strategies, challenges, and lessons … learned for QI implementation. … The AHRQ website includes valuable resources for practice facilitators along with lessons learned … Among these lessons, evaluators found that effective practice facilitators use a combination of the 

2623. Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/pichert.html
      August 01, 2017 - Lessons learned and limitations are discussed. Conclusion . … The planners learned important lessons worth consideration before health care leaders launch PARS or … People-Related Lessons. … Process-Related Lessons. … Systems-Related Lessons.

2624. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48169/psn-pdf
      July 24, 2019 - psnet.ahrq.gov/issue/50-years-inquiries-national-health-service https://psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations-bristol-royal … investigating-improvement-five-strategies-ensure-national-patient-safety-investigations https://psnet.ahrq.gov/issue/culture-change-nhs-applying-lessons-francis-inquiries

2625. 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

2626. Layout 1 (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/Telehealth_Issue_Paper_Final_1.pdf
      December 01, 2008 - learned from its portfolio of health IT projects. … learned, and future directions. … learned from the AHRQ-funded telehealth implementation projects. … The investigators learned that the practice staff enjoyed interacting with peers at other practices … The telehealth projects described in this report have brought to light a number of important lessons

2627. Using Telehealth to Improve Quality and Safety (pdf file)
      digital.ahrq.gov/sites/default/files/docs/lesson/09-0012-ef-telehealth.pdf
      December 01, 2008 - learned from its portfolio of health IT projects. … learned, and future directions. … learned from the AHRQ­funded telehealth implementation projects. … The investigators learned that the practice staff enjoyed interacting with peers at other practices … The telehealth projects described in this report have brought to light a number of important lessons

2628. Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
      April 06, 2008 - The PSO assesses the information from these sources and feeds back lessons learned to those health care … Using these reports and lessons learned, the PSO will populate its own database, as well as a national … also allows the PSO to focus on assisting and engaging health care providers with information and lessons … Moreover, lessons from efforts focused on the Problem Statement can then be fed to other health care … What we have learned from aviation and its applications to medicine.

2629. Errors in laboratory medicine: practical lessons to improve patient safety. | PSNet
      psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patient-safety
      February 14, 2024 - Commentary Classic Errors in laboratory medicine: practical lessons … Errors in laboratory medicine: practical lessons to improve patient safety. … Errors in laboratory medicine: practical lessons to improve patient safety.

2630. Clinical Decision Support Innovation Collaborative 2023-2024 (Year 3) Period of Performance Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/cdsic-year-3-report-2024.pdf
      January 01, 2024 - Key lessons learned include: Product Development and Pilot Project Implementation Foster collaboration … Section 4, Discussion, describes the lessons learned from the third year of the CDSiC, including the … • Workgroup support teams met internally on a weekly basis to share resources and lessons learned … The CDSiC’s efforts in the base years yielded several lessons learned about implementing a large-scale … Lessons learned in the base years and implemented in the third year include ensuring coordination across

2631. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853235/psn-pdf
      September 06, 2023 - When the lights go down in the delivery room: lessons from a ransomware attack. … When the lights go down in the delivery room: lessons from a ransomware attack. … https://psnet.ahrq.gov/issue/when-lights-go-down-delivery-room-lessons-ransomware-attack Cyberattacks … https://psnet.ahrq.gov/issue/when-lights-go-down-delivery-room-lessons-ransomware-attack https://psnet.ahrq.gov

2632. Florida Advisory Council Meeting
      hcup-us.ahrq.gov/datainnovations/clinicaldata/AdvisoryCouncilmeeting12032009_rev.jsp
      April 01, 2011 - Joining Clinical Laboratory Data to Administrative Inpatient Data Data Analysis Evaluation Survey Lessons … Learned and Conclusions Circular diagram of project stages with project description in center: … LOINC mapping, Data transmission, Communication tools, Barriers encountered, resolutions, and the lessons … learned. … Additional programming time was required to accommodate the change in data Lessons Learned

2633. Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
      August 01, 2022 - Summary Detailed Findings Evaluation Issues Contributions to Patient Safety and Medical Liability Lessons … Learned From Implementation Challenges Followup to the PSML Demonstration Projects Recommendations … This final evaluation report highlights the most substantive findings and lessons learned by the seven … findings) and an expanded description of the findings, our independent assessment of the findings, and lessons … learned follow in the full report and the individual grantee profiles in Appendix A .

2634. An Overview of the CANDOR Process
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
      September 10, 2015 - Medical liability carriers Mello et al: Communication-and-resolution programs: the challenges and lessons … learned from six early adopters6 Boothman and Hoyler: The University of Michigan's early disclosure … engage medical liability carriers include: Communication-and-resolution programs: the challenges and lessons … learned from six early adopters. … Communication-and-resolution programs: the challenges and lessons learned from six early adopters. 

2635. Simulation Facguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.docx
      May 01, 2017 - provides a structure for understanding the scenario and helps ensure that everyone will take away similar lessons … the process, describing what happened, conducting an analysis of team performance, and identifying lessons … learned. … Slide 20 SAY: The final step in the debriefing process is to identify lessons learned and look ahead … to how the team can generalize what they learned in the scenario to their daily practice.

2636. Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/waever.html
      August 01, 2017 - Safety Initiative Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons … Learned Implementing Shared Decision-Making: Barriers and Solutions—An Orthopedic Case Study Transitional … Five years after To Err Is Human: what have we learned? JAMA 2005; 293:2384–90. 2. … Communication-and-resolution programs: The challenges and lessons learned from six early adopters. … Lessons from the AHRQ Hospital Survey on Patient Safety Culture.

2637. IT Systems for Rural Indian Clinic Health Care | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/it-systems-rural-indian-clinic-health-care
      January 01, 2023 - Project Provides Lessons Learned For IT Implementations Along the way, the project has been a learning … Aranaydo has learned that each phase of IT implementation requires intense investment of staff time.

2638. Telehealth | Digital Healthcare Research
      digital.ahrq.gov/telehealth
      January 01, 2023 - Nonetheless, grantees have begun sharing "lessons learned" from their implementation efforts. … More lessons from the AHRQ telehealth portfolio ( PDF , 112 KB,  HTML ) . … One project (which used telehealth to give rural patients access to remote specialists) learned that

2639. A National Web Conference on the Use of Natural Language Processing (NLP) to Improve Quality Improvement (pdf file)
      digital.ahrq.gov/sites/default/files/docs/nlp-slides-041112.pdf
      April 11, 2012 - Quality (AHRQ) mailto:Brian.Hazlehurst@kpchr.org NLP to Measure Quality of Care in Diabetes: Lessons … Learned Alexander Turchin, MD, MS Brigham and Women’s Hospital Harvard Medical School Project … Ongoing Work CER HUB Asthma Care Quality (ACQ) Study NLP to Measure Quality of Care in Diabetes: Lessons … Learned Project Project Natural Language Processing Start with a Business Case Involve Domain

2640. A Picture Speaks 1000 Words | PSNet
      psnet.ahrq.gov/web-mm/picture-speaks-1000-words
      July 16, 2015 - July 16, 2015 Sharing lessons learned to prevent incorrect surgery. … Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons … learned.