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Showing results for "lessons learned".

  1. Advancing Patient Safety | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/advancing/index.html
    July 01, 2022 - carefully designed, developed, and evaluated. 2003 Launching AHRQ WebM&M To take advantage of the lessons … All of the lessons learned from these projects are helping health care providers move closer to a fully … We have learned that safety is a changing, emergent property of systems, and as our health care system … The promising beginnings and lessons learned in the first decade will serve us well as we undertake the

  2. Toolkit 1. Suspected UTI SBAR Toolkit (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T4-Urinalysis_and_UTIs_Improving_Care-updated.pdf
    October 01, 2016 - Toolkit 1. Suspected UTI SBAR Toolkit Nursing Home Antimicrobial Stewardship Guide Determine Whether To Treat Toolkit 1. Suspected UTI SBAR Toolkit Tool 4. Training Modules: Urinalysis and UTIs Improving Care Overview These training modules are designed to be flexible to meet your needs. Training coord…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35426/psn-pdf
    September 15, 2009 - explain the 2002 regulation of medical malpractice in China in the context of previous laws and identify lessons

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74119/psn-pdf
    November 24, 2021 - https://psnet.ahrq.gov/issue/learning-morbidity-and-mortality-conferences-focus-and-sustainability-lessons-patient-care

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33813/psn-pdf
    August 01, 2016 - efficiently detect dental charts that contain patient safety events.(2,16,17) One important point we have learned … Lessons learned from dental patient safety case reports. J Am Dent Assoc. 2015;146:318-326.e2.

  6. AHRQ Transforming Primary Care Grants Bibliography | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/reports/grants-transform/bibliography/index.html
    February 01, 2017 - Lessons learned from the study of primary care transformation. … PMID: 23690378 The authors summarized the overarching lessons learned from 14 research studies funded … Five lessons learned were identified across studies: 1) a strong foundation (including structural capacity … Return to Contents A Study of the PCMH: Lessons From a New York State Community Health Center … Leaders learned essential and different leadership skills in each phase.

  7. AHRQ Transforming Primary Care Grants | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/research-transform-primary-care/transform/tpcbib/index.html
    May 01, 2015 - Lessons learned from the study of primary care transformation. … PMID: 23690378 The authors summarized the overarching lessons learned from 14 research studies funded … Five lessons learned were identified across studies: 1) a strong foundation (including structural capacity … Return to Contents A Study of the PCMH: Lessons From a New York State Community Health Center … Leaders learned essential and different leadership skills in each phase.

  8. Training and Events Calendar | The Academy

    integrationacademy.ahrq.gov/news-and-events/calendar
    January 01, 2025 - This session will highlight lessons from a statewide telebehavioral health initiative serving more than …
  9. Lessons learned on rollout, staff buy-in, and ethical considerations. … Learned through Integrated Care Concept Planning This session, hosted by the National Council … Panelists will share insights from implementation efforts, including lessons learned from clinical trials …
  10. Discuss implementation challenges and lessons learned from sites that have successfully expanded

  • Quality improvement priorities for safer out-of-hours palliative care: lessons from a mixed-methods analysis of a national incident-reporting database. | PSNet

    psnet.ahrq.gov/issue/quality-improvement-priorities-safer-out-hours-palliative-care-lessons-mixed-methods-analysis
    July 03, 2016 - Study Quality improvement priorities for safer out-of-hours palliative care: lessons … Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis … Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis

  • Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system. | PSNet

    psnet.ahrq.gov/issue/error-reduction-trauma-care-lessons-anonymized-national-multicenter-mortality-reporting
    March 24, 2021 - Study Error reduction in trauma care: lessons from an anonymized, national, multicenter … Error reduction in trauma care: Lessons from an anonymized, national, multicenter mortality reporting … Error reduction in trauma care: Lessons from an anonymized, national, multicenter mortality reporting

  • Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan. | PSNet

    psnet.ahrq.gov/issue/developing-health-care-organizations-pursue-learning-and-exploration-diagnostic-excellence
    October 28, 2020 - September 1, 2021 Ebola US Patient Zero: lessons on misdiagnosis and effective use of

  • Project Report - Lean Sigma (ppt file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/nurse_empower-slides/How-CUSP-Enables-Nurse-Empowerment-Nov-15-2011-508.ppt
    January 01, 2011 - leadership team * Slide * SICU Huddle Board * Slide * Surgical Unit Huddle Board Slide * Lessons … Administrator tries to “solve” problem rather than listen Being afraid of airing dirty laundry * Slide * Lessons

  • Sustainability Module | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/slides.html
    October 01, 2020 - Encourage your team leaders to discuss actual patient stories to drive home important lessons. … Incorporate evaluation findings – Initiate breakthrough conversations 4 – Share proven safe practices and lessons … learned Review data regularly by senior leadership and all facility stakeholders Slide 37: Sustainability

  • Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73331/psn-pdf
    May 26, 2021 - cancer-diagnoses-delayed-among-prisoners-washington-state Delays and mistakes in health care for distinct patient populations hold improvement lessons

  • Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33671/psn-pdf
    July 01, 2008 - The focus is on individuals, rules, and sanctions; therefore, lessons learned are not shared.

  • Situation Monitoring: Severe Hypertension (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring-speaker-notes.pdf
    July 01, 2023 - their responsibilities • Reassess how the team is working together 7 SCRIPT As we’ve already learned … • What were our major lessons learned from this case? … • Summarize your major takeaways by asking what the team’s lessons 27 learned were from this … that debriefs are learning opportunities, your team will want to give some consideration to how the lessons … Make sure to spend some time talking about how to apply any lessons learned into practice for future

  • The Soil, Not the Seed: The Real Problem with Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
    March 01, 2007 - The focus is on individuals, rules, and sanctions; therefore, lessons learned are not shared.

  • Quality Diagnostic Tools for States | Agency for Healthcare Research and Quality

    www.ahrq.gov/cpi/centers/ockt/kt/tools/index.html
    November 01, 2017 - Quality Diagnostic Tools for States The Quality Diagnostic Tools for States program consists of events and technical assistance opportunities that disseminate and encourage the use of Quality Improvement tools from the Agency for Healthcare Research and Quality (AHRQ), created to support State policymakers with…

  • Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33650/psn-pdf
    May 01, 2007 - 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

  • AHRQ Issue Brief: Understanding the AI Wave: Foundational Knowledge for Improving Diagnosis and Beyond (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-brief-ai-wave.pdf
    June 01, 2025 - Moving Forward.....................................................................................10 Lessons … Like the toddler misclassifying the red block, the model has learned the wrong rule. … Insights from other high-risk industries that have successfully adapted to automation offer valuable lessons … into high-risk environments—such as aviation, nuclear power, and manufacturing—offer important lessons … As healthcare moves to integrate AI more deeply into clinical care, applying these lessons requires
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