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Total Results: 5,376 records

Showing results for "lessons learned".

361. Recognizing Unsafe Care: What It Is and How to Report It. | PSNet
     psnet.ahrq.gov/issue/recognizing-unsafe-care-what-it-and-how-report-it
     April 22, 2020 - June 21, 2023 Lessons Learned about Human Fallibility, System Design, and Justice in … May 8, 2017 A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing

362. Patient, Medical, and Legal Perspectives of Unsafe Care. | PSNet
     psnet.ahrq.gov/issue/patient-medical-and-legal-perspectives-unsafe-care
     July 20, 2021 - June 1, 2021 The evolution of the Anesthesia Patient Safety Movement in America: lessons … learned and considerations to promote further improvement in patient safety. … September 7, 2022 Lessons Learned about Human Fallibility, System Design, and Justice

363. Human factors engineering: its place and potential in OR safety. | PSNet
     psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety
     May 24, 2017 - September 28, 2022 Lessons learned implementing a complex and innovative patient safety … January 18, 2023 Lessons learned in implementing a chronic opioid therapy management … Lessons from aviation to improve patient safety.

364. CDSiC Year 3 Period of Performance Report | CDSiC
     cdsic.ahrq.gov/cdsic/year3-period-performance-report
     September 30, 2024 - an overview of CDSiC activities, outputs, and outcomes during the project's third year and summarize lessons … learned. … as those interested in learning about and tracking the CDSiC's key activities, accomplishments, and lessons … learned.

365. A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and its meetings. | PSNet
     psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its
     March 04, 2015 - describes one hospital's experience implementing  Failure Mode and Effects Analysis and highlights lessons … learned. … April 28, 2021 Shaping systems for better behavioral choices: lessons learned from a

366. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. | PSNet
     psnet.ahrq.gov/issue/national-trauma-care-system-integrating-military-and-civilian-trauma-systems-achieve-zero
     September 12, 2018 - This report discusses the need to ensure that lessons learned in military trauma care are acted on … May 12, 2021 Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis.

367. The safe day call: reducing silos in health care through frontline risk assessment. | PSNet
     psnet.ahrq.gov/issue/safe-day-call-reducing-silos-health-care-through-frontline-risk-assessment
     May 25, 2016 - The authors review the results and lessons learned in the 4 years following the intervention. … October 1, 2014 Project BOOST implementation: lessons learned.

368. Chapter 4. Evaluation Design | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/diabetesnetwork/diabnet4.html
     October 01, 2014 - What were lessons learned at the clinic level in implementing this patient self-management intervention … What were the key lessons learned relative to conducting this learning network initiative for community … Lessons learned in patient self-management Patient Self-Management Tools/Steps … Lessons learned in decision support Decision Support Tools/Steps Resources … Tips/Lessons Learned Determine any changes that could support better decision making in clinic.

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33657/psn-pdf
     September 01, 2007 - This redesign fosters a culture of safety by constantly reinforcing the lessons learned at the weekly … This is a talent and a skill that can be learned. … How can a department assure itself that these lessons are being learned? … Since so many lessons are covered each year, new members no longer have to rediscover gravity! … from real-life cases, and to make those lessons into a living curriculum.

370. Emerging-Strategies-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/emerging-strategies-slides.pdf
     August 12, 2020 - Adjusting programs to less frequency -Priority focus for in-person time -Adjustments to monitoring Lessons … Learned and Emerging Challenges … 12 Lessons Learned What lessons have you learned or challenges are you

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33775/psn-pdf
     December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned December 1, 2014 Syed SS. … African Partnerships for Patient Safety: Lessons Learned. PSNet [internet]. 2014. … https://psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned Perspective … health workers in Africa and https://psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned … APPS focused on influencing national patient safety initiatives by highlighting what had been learned

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851869/psn-pdf
     July 31, 2023 - learning organizations use high-reliability principles, develop feedback loops, and share findings and lessons … learned with other learning systems. … Debriefing skills learned in simulation can also be applied to actual patient care. … learned. … learned is the concern for potential litigation and liability.

373. Pohl, Joanne | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/pohl-joanne
     January 01, 2023 - Diabetes and hypertension quality measurement in four safety-net sites: lessons … learned after implementation of the same commercial electronic health record. … Diabetes and hypertension quality measurement in four safety-net sites: lessons learned after implementation

374. Creating a Communication Coaching Structure and Support for your CRP Program. | PSNet
     psnet.ahrq.gov/issue/creating-communication-coaching-structure-and-support-your-crp-program
     January 25, 2023 - October 19, 2022 View More Related Resources Lessons Learned about … June 26, 2019 A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing

375. Smart pumps: implications for nurse leaders. | PSNet
     psnet.ahrq.gov/issue/smart-pumps-implications-nurse-leaders
     February 02, 2022 - February 29, 2012 Intravenous medication safety and smart infusion systems: lessons learned … March 22, 2011 Intravenous medication safety and smart infusion systems: lessons learned

376. The role of practice guidelines and evidence-based medicine in perioperative patient safety. | PSNet
     psnet.ahrq.gov/issue/role-practice-guidelines-and-evidence-based-medicine-perioperative-patient-safety
     June 26, 2024 - Citation Related Resources From the Same Author(s) Quality improvement lessons … learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation … December 14, 2010 SafetyNet: Lessons Learned from Close Calls in the OR.

377. Spotlight on Illinois -- The National Evaluation of the CHIPRA Quality Demonstration Grant Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-illinois-state-snapshot.pdf
     January 01, 2018 - CHIPRA Quality Demonstration Grant Program January 2018 This brief highlights the major strategies, lessons … learned, and outcomes from Illinois’s experience from February 2010 to February 2016 with the quality … Partner States: Illinois and Florida implemented similar projects and met monthly to share lessons learned … • Build on lessons learned from the CHIPRA quality demonstration to design a Statewide multipayer … /chipra/demoeval/what-we-learned/highlight12.html https://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned

378. Becoming a high-reliability organization through shared learning of safety events | PSNet
     psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events
     February 12, 2020 - December 19, 2012 Lessons learned from a death outside a hospital's doorstep. … March 22, 2023 Lessons learned from a systems approach to engaging patients and families

379. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
     February 01, 2015 - learned that still represent a challenge. … While all the lessons learned are yet to be recorded and digested, the relevance of simulation extends … Learned From Simulation and Training Myriad lessons have been learned since the launch of AHRQ’s grant … are yet to be learned. … Given that unexpected events will occur, there are lessons to be learned regarding their anticipation

380. Featured Sessions | Digital Healthcare Research
     digital.ahrq.gov/featured-sessions
     January 01, 2023 - learned" from a real world experience adapting existing infrastructure, identifying patients, and handling … LLP ( PDF , 604.54 KB) Tuesday, June 6th, 2006 11:45 am - 12:45 pm Room: 16 Wrap-up Session and Lessons … Learned with Carolyn Clancy As the final wrap-up for the 2006 AHRQ Patient Safety and Health IT Meeting … present information summarizing the content and key takeaways from their tracks highlighting insights, lessons … learned and practical recommendations offered by our presenters Facilitators: Carolyn Clancy, Marge