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Showing results for "lessons learned".

3481. Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - Organizations can move forward and commit to reestablishing patient safety as their purpose through lessons … learned during the pandemic. … We had weekly calls and huddles with colleagues who shared their experiences and lessons learned. … examples of early adopters, and have actively and transparently shared their experience, progress, and lessons … learned in webinars and at conferences and are paving the way for all organizations to reset and fortify

3482. Mod03-Gap-Analysis-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
      April 01, 2016 - Are claims and lawsuits tracked and analyzed for lessons learned? k. … Are claims and lawsuits tracked and analyzed for lessons learned?

3483. Facilitator Guide: Engage Senior Executives in Surgical Site Infection Prevention Work (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_sr-execs_facnotes.docx
      December 01, 2017 - successful strategies for engaging your executive in this program We ask that you share what you have learned … These lessons can be shared broadly across the organization. … ASK: Currently, do you have mechanisms to systematically capture and share lessons learned and successes

3484. Engaging Senior Executives: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/sr-exec-slides.html
      December 01, 2017 - We ask that you share what you have learned with your team. … These lessons can be shared broadly across the organization. … Ask: Currently, do you have mechanisms to systematically capture and share lessons learned and successes

3485. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33837/psn-pdf
      July 01, 2017 - adverse events to https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters … https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters

3486. Using Health IT to Improve Care Coordination and Outcomes in Patients with Complex Health Care Needs (pdf file)
      digital.ahrq.gov/sites/default/files/docs/coordination-patients-complex-needs-slides-022014.pdf
      February 20, 2014 - Increasing nurses’ knowledge, comfort with, and motivation to use IT—especially per diem nurses 47 Lessons … Learned More nurse engagement pre-intervention development and during implementation to learn about … CDS use Patient Outcomes by CDS Use Conclusions Implications for Policy, Delivery, and Practice Lessons … Learned Acknowledgments Acknowledgments (continued) Improving Care Transitions for Complex Patients

3487. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852700/psn-pdf
      August 30, 2023 - We had weekly calls and huddles with colleagues who shared their experiences and lessons learned. … examples of early adopters, and have actively and transparently shared their experience, progress, and lessons … learned in webinars and at conferences and are paving the way for all organizations to reset and fortify

3488. Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error Evaluation and Research (DEER) Project (pdf file)
      www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
      January 01, 2025 - learned. … We learned that diagnosis errors, though common and under-emphasized, are also challenging to detect … From our preliminary analysis we learned: 1) Our reported diagnosis error cases illustrate a wide spectrum … Diagnosing Diagnostic Errors: Lessons from a Multi- Institutional Collaborative Project. … AHRQ diagnosis error project: Lessons learned. Chicago Patient Safety Forum.

3489. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49664/psn-pdf
      January 01, 2013 - Despite very clear contextual differences, every complex system aims for improvement, and translating lessons … Handoff strategies in settings with high consequences for failure: lessons for health care operations

3490. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
      November 01, 2008 - decision-making (e.g., transfer patient now versus incur more shift changes & sign-outs) Assumptions & Lessons … Available at: http://www.ncbi.nlm.nih.gov/pubmed/18245211 Assumptions & Lessons (from Cognitive … contingency plans, and allow for flexibility to deviate in exceptional circumstances Assumptions & Lessons … page=637&calcTitle=1&title_id=9545&edition_id=10284 Assumptions & Lessons (3) (from Cognitive Engineering

3491. PCOR Trust Fund Investments At-A-Glance | Agency for Healthcare Research and Quality
      www.ahrq.gov/pcor/at-a-glance/index.html
      October 01, 2024 - AHRQ uses learning collaboratives among grantees to share valuable lessons, resources, curriculum, and

3492. State at a Glance: Massachusetts | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/demoeval/demostates/ma.html
      March 01, 2019 - What are the key lessons from Massachusetts's experience that would be useful for other States?

3493. Zero preventable deaths after traumatic injury: an achievable goal. | PSNet
      psnet.ahrq.gov/issue/zero-preventable-deaths-after-traumatic-injury-achievable-goal
      March 24, 2021 - March 24, 2021 Error reduction in trauma care: lessons from an anonymized, national,

3494. Data consistency in a voluntary medical incident reporting system. | PSNet
      psnet.ahrq.gov/issue/data-consistency-voluntary-medical-incident-reporting-system
      August 21, 2024 - April 8, 2018 Lessons learnt from incidents reported by postgraduate trainees in Dutch

3495. Evidence-based medicine: a cornerstone for clinical care but not for quality improvement. | PSNet
      psnet.ahrq.gov/issue/evidence-based-medicine-cornerstone-clinical-care-not-quality-improvement
      September 01, 2021 - The Continued Call for Health Systems Science Curricula February 1, 2019 Lessons

3496. Leveraging trainees to improve quality and safety at the point of care: three models for engagement. | PSNet
      psnet.ahrq.gov/issue/leveraging-trainees-improve-quality-and-safety-point-care-three-models-engagement
      September 20, 2017 - education with clinical care October 2, 2019 Teaching patient safety in global health: lessons

3497. The future of graduate medical education: a systems-based approach to ensure patient safety. | PSNet
      psnet.ahrq.gov/issue/future-graduate-medical-education-systems-based-approach-ensure-patient-safety
      October 18, 2017 - View More Related Resources Teaching patient safety in global health: lessons

3498. Use of medical abbreviations and acronyms: knowledge among medical students and postgraduates. | PSNet
      psnet.ahrq.gov/issue/use-medical-abbreviations-and-acronyms-knowledge-among-medical-students-and-postgraduates
      August 23, 2023 - July 28, 2021 The Lancet Commission on lessons for the future from the COVID-19 pandemic

3499. Patient safety: numerical skills and drug calculation abilities of nursing students and Registered Nurses. | PSNet
      psnet.ahrq.gov/issue/patient-safety-numerical-skills-and-drug-calculation-abilities-nursing-students-and
      July 08, 2020 - April 26, 2017 The Lancet Commission on lessons for the future from the COVID-19 pandemic

3500. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly what it was. | PSNet
      psnet.ahrq.gov/issue/really-stupid-mistake-it-does-feel-cop-out-blame-my-error-human-frailty-im-afraid-thats
      August 16, 2023 - suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons