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Showing results for "lessons learned".

2861. An organizational learning framework for patient safety. | PSNet
      psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
      November 28, 2018 - patient safety training January 13, 2021 Teaching patient safety in global health: lessons

2862. Diagnostic error in a national incident reporting system in the UK. | PSNet
      psnet.ahrq.gov/issue/diagnostic-error-national-incident-reporting-system-uk
      February 15, 2013 - 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

2863. Making Healthcare Safer Practices: 15. Care Transitions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/care-transitions-1.pdf
      March 01, 2020 - Project BOOST implementation: Lessons learned. … Implementation of the care transitions intervention: Sustainability and lessons learned. … Lessons learned from implementing a pilot rct of transitional care model for individuals with serious … Implementation of the care transitions intervention: Sustainability and lessons learned. … The pilot study had reflections and lessons learned, but no concrete outcomes.

2864. Small and Rural Critical Access Hospitals (Slide Presentation) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals/slides.html
      October 01, 2014 - Add science of safety education to orientation Learn from one defect per quarter; share or post lessons … Agenda Why we joined the CLABSI & CAUTI projects Barriers and successes Key lessons Return … Agenda Why we joined the CLABSI & CAUTI projects Barriers and successes Key lessons Return

2865. Resilient Health Care Series. | PSNet
      psnet.ahrq.gov/issue/resilient-health-care-series
      October 25, 2018 - American Pathologists Special Topic Symposium on Error in Pathology and Laboratory Medicine—Practical Lessons … April 6, 2016 Culture Change in the NHS: Applying the Lessons of the Francis Inquiries

2866. Nursing Home Workplace Safety Resource List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
      January 01, 2023 - learned to improve the well-being of the healthcare workforce, including actions that individuals, … Lessons From Nursing Home Staff To Address Burnout and Enhance Joy in Work https://www.ihi.org/communities … /blogs/lessons-from-nursing-home-staff-to-address- burnout-and-joy-in-work (requires free account setup … https://www.ihi.org/communities/blogs/lessons-from-nursing-home-staff-to-address-burnout-and-joy-in-work … Leadership, Management, and Quality Improvement Leading a Culture of Safety: A Blueprint for Success Lessons

2867. Using CAHPS Clinician & Group Survey Data | Agency for Healthcare Research and Quality
      www.ahrq.gov/cahps/surveys-guidance/cg/using-data/index.html
      December 01, 2023 - Lessons From Healthcare Organizations on Improving Patient Experience . … Achieving Excellence Across All CG-CAHPS Core Measures: Lessons from Top-Performing Medical Practices … Providing Performance Feedback to Individual Physicians: Current Practice and Emerging Lessons .

2868. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72614/psn-pdf
      March 01, 2021 - Structured communication techniques: Participants learned structured communication, teamwork and situational … Participants also received and learned to use forms to document communication. … Chair of the Department of Obstetrics and Gynecology and now Director of PROMPT for North America, learned … Adoption Considerations Lessons Learned The PROMPT program has won numerous awards in the United Kingdom … Lessons from a series of research on teamwork, leadership and team training.

2869. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61031/psn-pdf
      October 14, 2020 - tools such as failure mode and effect analysis and root cause analysis may be amended to optimize how lessons

2870. Assessing the Impact of Indexing Performance Measure Codes on the Perceived Value of EPC Reports to Health Systems (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/methods-assessing-impact.pdf
      September 01, 2018 - • Lessons Learned for EPC Program: There are small enhancements to our current reports which can … Learned and Applicability for Other EPC Reports .................................................... … Lessons Learned and Applicability for Other EPC Reports It took a while for our group to understand … Learned and Applicability for Other EPC Reports Conclusions References Abbreviations and Acronyms … Learned and Applicability for Other EPC Reports Conclusion References Abbreviations and Acronyms

2871. Are you surgically current? Lessons from aviation for returning to non-urgent surgery following COVID-19. | PSNet
      psnet.ahrq.gov/issue/are-you-surgically-current-lessons-aviation-returning-non-urgent-surgery-following-covid-19
      September 29, 2021 - Lessons from aviation for returning to non-urgent surgery following COVID-19. … Lessons from aviation for returning to non-urgent surgery following COVID-19. … Lessons from aviation for returning to non-urgent surgery following COVID-19. … March 9, 2022 Crisis management for surgical teams and their leaders, lessons from the … Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons

2872. In Conversation with...Sir Liam Donaldson, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
      May 01, 2007 - That's where we can go back to the lessons of the airline industry. … What have you learned about the commonalities and differences as you try to share patient safety learnings … It described the NHS as having an old-fashioned approach to learning lessons when things go wrong and … Mechanisms for ensuring that, where lessons are identified, the necessary changes are put into practice … 2001, charged with establishing a national reporting and learning system for adverse events, taking lessons

2873. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47398/psn-pdf
      December 22, 2018 - imitating-incidents-how-simulation-can-improve-safety-investigation-and-learning-adverse https://psnet.ahrq.gov/primer/simulation-training https://psnet.ahrq.gov/issue/flying-lessons-clinicians-developing-system

2874. Simulation-Based Education Improves Patient Safety in Ambulatory Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Lavelle_33.pdf
      March 12, 2008 - a lot” that would help them clinically, and 13 percent “learned some.” … Lessons Learned Most of our “lessons learned” were associated with implementation rather than planning … Medication “lessons learned” included: • Since most pharmacists and nurses are outpatient-based and … Settings Comparing Clinic and Urgent Care Staff Discussion Drivers for Using Simulation Curriculum Lessons … Learned Safety Concerns Next Steps Conclusion Acknowledgments Author Affiliations References

2875. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
      December 01, 2017 - Share what you’ve learned with your team. … developing handouts, posters, or newsletter articles to help introduce and reinforce the concepts you’ve learned … We ask that you share what you’ve learned with your teams. … Slide 31: Lessons Learned Say: To review the main components of this module, consider these thoughts

2876. CDS Connect Implementation Guide Draft (doc file)
      cds.ahrq.gov/sites/default/files/cds/artifact/18/Enhanced%20CDS%20Artifact%20Based%20on%20Pilot%20Implementation_Final.docx
      October 01, 2017 - Lessons Learned and Broader Implications 12 4.1 Coding variations 12 4.1.1 Conditions 12 4.1.2 Procedures … Agency for Healthcare Research and Quality (AHRQ) Lessons Learned and Broader Implications Agency for … Pilot Experience 12 Enhanced Clinical Decision Support Artifact Based on Pilot Experience 14 Lessons … Learned and Broader Implications The findings and discussions that arose during the development and

2877. Teamworknotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamworknotes.docx
      June 02, 2025 - events, · An analysis of why an event occurred, what worked, and what did not work, · A discussion of lessons … learned and how staff will alter the plan next time, and · The establishment of a method to formally … change the existing plan to incorporate lessons learned. … a resolution that all parties find acceptable. · Frame problems in terms of personal experience and lessons … learned. · A private location away from the patient or other team members will allow both parties to

2878. Implement Teamwork and Communication for Perinatal Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
      May 01, 2017 - events, • An analysis of why an event occurred, what worked, and what did not work, • A discussion of lessons … learned and how staff will alter the plan next time, and • The establishment of a method to formally … change the existing plan to incorporate lessons learned. … • Frame problems in terms of personal experience and lessons learned.

2879. Interactive Patient-Centered Discharge Toolkit - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs024751-dalal-final-report-2019.pdf
      January 01, 2019 - Lessons learned should help other institutions considering how to implement EHR-integrated digital … In short, the lessons learned from our experience should have practical implications for other institutions … emerging workflows for identifying and escalating discharge barriers • Propose enhancements based on lessons … learned from concurrent QI efforts Poor specificity of patient-reported concerns viewed in dashboard

2880. AHRQ Step Up Challenge Summary (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/ahrq-step-up-app-challenge-summary-2019.pdf
      January 01, 2019 - Lessons Learned 17 15 EXECUTIVE SUMMARY The AHRQ Step Up App Challenge encouraged … can use these data to answer questions that would not have been able to be answered. 117 LESSONS … LEARNED Identify all key technical requirements for 1. each phase before launch to decrease participants