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Showing results for "lessons learned".

2821. Title Page (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r01hs015409-overhage-final-report-2009.pdf
      January 01, 2009 - Results: We learned a variety of lessons during the course of our study. … Results Principal Findings We have learned a variety of lessons during the course of our study that … A third important lesson that we have learned is how to think about the results of economic models for

2822. ABCDEF Bundle Data Literacy Training, Performance Measurement Tracking, and Performance Feedback | PSNet
      psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
      September 23, 2024 - Operations Business Intelligence, Value Improvement Office (referred to throughout as the Innovation Team) learned … Lessons learned from a systematic, hospital-wide implementation of the ABCDEF bundle: a survey evaluation … Lessons Learned From a Systematic, Hospital-Wide Implementation of the ABCDEF Bundle: A Survey Evaluation

2823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33753/psn-pdf
      August 22, 2013 - Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented

2824. Transformational improvement in quality care and health systems: the next decade. | PSNet
      psnet.ahrq.gov/issue/transformational-improvement-quality-care-and-health-systems-next-decade
      October 14, 2020 - Annual Perspective Equity in Patient Safety March 27, 2024 Lessons … Improving Diagnostic Safety and Quality April 26, 2023 The Lancet Commission on lessons

2825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42525/psn-pdf
      November 20, 2013 - promise-learn-commitment-act-improving-safety-patients-england https://psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care

2826. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
      June 01, 2005 - Are there lessons there for other institutions? PP: There were a number of important factors. … What lessons from your experience with Hopkins are generalizable? … PP: One of the lessons in overseeing quality and safety at Hopkins is that our center could never be … We have learned there were many ways of identifying defects: M&M conferences, incident-reporting systems … Yet we also learned that despite all this, we often fail to learn from these defects; mistakes recur.

2827. Interpreting the Patient Safety Literature | PSNet
      psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
      June 01, 2005 - Are there lessons there for other institutions? PP: There were a number of important factors. … What lessons from your experience with Hopkins are generalizable? … PP: One of the lessons in overseeing quality and safety at Hopkins is that our center could never be … We have learned there were many ways of identifying defects: M&M conferences, incident-reporting systems … Yet we also learned that despite all this, we often fail to learn from these defects; mistakes recur.

2828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44089/psn-pdf
      April 22, 2015 - root-cause-analysis https://psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident

2829. A multi-tiered approach to safety education. | PSNet
      psnet.ahrq.gov/issue/multi-tiered-approach-safety-education
      January 31, 2018 - July 10, 2019 The Lancet Commission on lessons for the future from the COVID-19 pandemic … Sustaining quality improvement and patient safety training in graduate medical education: lessons

2830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837791/psn-pdf
      August 05, 2022 - maintaining adequate access to ambulatory care and reliable diagnostic services, have been informed by lessons … Next Steps in Ambulatory Care Safety Over the last three decades, many lessons have been learned and … These demonstration and implementation projects could further accelerate the application of lessons … learned to help safety leaders better understand and, ultimately, decrease adverse events in ambulatory

2831. Understanding and learning from organisational failure. | PSNet
      psnet.ahrq.gov/issue/understanding-and-learning-organisational-failure
      April 19, 2011 - Citation Related Resources From the Same Author(s) A very public failure: lessons

2832. Module 1: Communication and Optimal Resolution (CANDOR) Toolkit Module 1: An Overview of the CANDOR Process
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/module1-overview.pptx
      June 02, 2025 - The CANDOR process promotes the value of disseminating lessons learned and solutions to prevent harm … Disclosure Module 1 11 Begins within 60 minutes after an has been identified and continues as more is learned … Disclosure process begins 60 minutes after a CANDOR event has been identified and continues as more is learned

2833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46446/psn-pdf
      September 27, 2017 - journey-toward-high-reliability-comprehensive-safety-program-improve-quality-care-and-safety https://psnet.ahrq.gov/primer/high-reliability https://psnet.ahrq.gov/issue/error-management-lessons-aviation … https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations

2834. The IHA Bundled Episode Payment and Gainsharing Demonstration | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/delivery-initiative/bozicstudysnapshots/index.html
      August 01, 2018 - This study snapshot presents lessons learned from the demonstration. By M. … Return to Contents Takeaway Points The demonstration generated the following lessons for those

2835. Preface | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/preface.html
      March 01, 2016 - New in This Guide This revision reflects important changes in the environment, new guidelines, and lessons … learned. … More specifically, this version presents: Lessons from collaboratives and success stories: The first

2836. EvidenceNOW: Southwest Cooperative | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/southwest.html
      March 01, 2021 - Disseminate the findings to key local, regional, and national stakeholders, including sharing ongoing lessons … learned and resources. … Oregon Health Services Center, 2016] Collective Efforts to Overcome Quality Measurement Challenges: Lessons

2837. Preface | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/vtguide/preface.html
      March 01, 2016 - New in This Guide This revision reflects important changes in the environment, new guidelines, and lessons … learned. … More specifically, this version presents: Lessons from collaboratives and success stories: The first

2838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60363/psn-pdf
      March 01, 2021 - Lessons learned from the Care Transitions Intervention. Open Longevity Science 2010;(4):43-50. … Implementation of the Care Transitions Intervention: Sustainability and lessons learned. … a2d4c12d120088066df4638da356cf65/51_Implementation- of-the-Care-Transitions-Intervention-Sustainability-and-Lessons-Learned.pdf … a2d4c12d120088066df4638da356cf65/51_Implementation-of-the-Care-Transitions-Intervention-Sustainability-and-Lessons-Learned.pdf … a2d4c12d120088066df4638da356cf65/51_Implementation-of-the-Care-Transitions-Intervention-Sustainability-and-Lessons-Learned.pdf

2839. AcademyHealth Electronic Data Methods (EDM) Forum for Comparative Effectiveness Research - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/u13hs19564-holve-final-report-2013.pdf
      January 01, 2013 - To maximize the lessons learned from this unprecedented investment in new infrastructure for health and … healthcare, AHRQ created the EDM Forum to foster dialogue on lessons learned by networks with diverse … Philip Payne, the Ohio State University); and generalizable lessons learned for future research and … Over the past three years, the EDM Forum team and collaborators have learned several important lessons … Building the Electronic Clinical Data Infrastructure: Lessons Learned from Research and QI Networks.

2840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848827/psn-pdf
      May 10, 2023 - learning-safety-incidents-high-reliability-organizations-systematic-review-learning-tools https://psnet.ahrq.gov/issue/error-reduction-trauma-care-lessons-anonymized-national-multicenter-mortality-reporting