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psnet.ahrq.gov/issue/what-do-we-really-know-about-crew-resource-management-healthcare-umbrella-review-crew
September 29, 2021 - the need for future research to expand beyond acute care and to investigate the sustainability of lessons … learned from CRM trainings. … View More
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Understanding ultrarare adverse events - lessons … learned from a twelve-year review of intraoperative deaths at an academic medical center.
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psnet.ahrq.gov/issue/computerized-provider-order-entry-implementation-no-association-increased-mortality-rates
November 16, 2022 - The authors noted that the lessons learned from the initial implementation problems were essential to … July 3, 2016
Project BOOST implementation: lessons learned.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
December 01, 2017 - Slide 9
Lessons Learned = Sustaining the Gain
Ensure administration is aware of your efforts … Slide 10
Lessons Learned = Sustaining the Gain
Keep CAUTI project on the “front burner” … Slide 11
Lessons Learned = Sustaining the Gain
Continue to work on staff competency (insertion … Slide 13
Lessons Learned = Sustaining the Gain
Treat a “CAUTI with respect – Learning from … Slide 15
Lessons Learned = Sustaining the Gain
Data drives practice and improvement….
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psnet.ahrq.gov/issue/mortality-and-morbidity-meetings-untapped-resource-improving-governance-patient-safety
June 25, 2014 - April 5, 2023
Governing patient safety: lessons learned from a mixed methods evaluation … 29, 2014
Prospects for comparing European hospitals in terms of quality and safety: lessons … January 29, 2014
Governing patient safety: lessons learned from a mixed methods evaluation
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psnet.ahrq.gov/issue/adverse-health-care-events-reporting-system-what-have-we-learned
February 28, 2015 - Book/Report
Adverse Health Care Events Reporting System: What Have We Learned? … Citation Text:
Adverse Health Care Events Reporting System: What Have We Learned? St. … Citation
Citation Text:
Adverse Health Care Events Reporting System: What Have We Learned … U.S. compounding pharmacy-related outbreaks, 2001--2013: public health and patient safety lessons … learned.
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psnet.ahrq.gov/issue/oversedation-patient-obstructive-sleep-apnea-prior-imaging
September 02, 2020 - Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons … learned. … January 17, 2017
Shaping systems for better behavioral choices: lessons learned from
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/supplhighlight06.html
January 01, 2014 - The States intentionally delayed the implementation of Idaho’s project so that it could leverage the lessons … learned from Utah’s early experiences. … not an area of collaboration for the partners, they do share information on progress, challenges, and lessons … learned.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/tpc-profile-gabbay.pdf
April 01, 2015 - The
practices focused on improving the care of patients with diabetes,
with the goal of applying lessons … learned and practice changes to
other patient populations. … Lessons Learned and Implications for Others
• Supplemental financial support was critical to PCMH transformation … Location
Transformational Elements
Key Impacts of Transformation
Challenges to Transformation
Lessons … Learned and Implications for Others
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/statesummaries/chipra-750-georgia-state-snapshot.pdf
January 01, 2018 - Evaluation of the CHIPRA Quality Demonstration Grant Program
This brief highlights the major strategies, lessons … learned,
and outcomes from Georgia’s experience from February
2010 to February 2016 with the quality … • Disseminated lessons learned in peer support to
other States. … highlight06.pdf
http://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned … /highlight07.pdf
http://www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/implementation-guides
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www.ahrq.gov/sites/default/files/publications2/files/takeheart-hybrid-workgroup-evaluation.pdf
August 01, 2023 - Abt staff led discussions
regarding Workgroup activities, lessons learned, and future plans, while Dr … learned. … This guide incorporated relevant insights and lessons
learned captured through each process described … • Lessons learned and recommendations that are important to AHRQ but not well-suited
for the Implementation … The
guide will also incorporate lessons learned/captured from the workgroup participants and
invited
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psnet.ahrq.gov/issue/medication-safety-during-covid-19-pandemic-what-have-we-learned-united-states
January 13, 2021 - Webinar
Medication Safety During the COVID-19 Pandemic: What Have We Learned in the … Citation Text:
Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States … Citation
Citation Text:
Medication Safety During the COVID-19 Pandemic: What Have We Learned … June 21, 2023
Lessons Learned about Human Fallibility, System Design, and Justice in
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psnet.ahrq.gov/issue/i-had-no-idea-happened-electronic-feedback-clinical-reasoning-hospitalists
February 28, 2024 - Download Citation
Related Resources From the Same Author(s)
Exploring clinical lessons … learned by experienced hospitalists from diagnostic errors and successes. … June 12, 2024
Exploring clinical lessons learned by experienced hospitalists from diagnostic
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psnet.ahrq.gov/node/43315/psn-pdf
May 10, 2016 - this commentary relates how two organizations implemented this strategy along
with challenges and lessons … learned. … psnet.ahrq.gov/issue/sustaining-quality-improvement-and-patient-safety-training-graduate-medical-education-lessons
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psnet.ahrq.gov/node/837975/psn-pdf
August 31, 2022 - analyzing-and-discussing-human-factors-affecting-surgical-patient-safety-
using-innovative
Leveraging lessons … learned in aviation, patient safety researchers have begun exploring the use of medical
data recorders … analyzing-and-discussing-human-factors-affecting-surgical-patient-safety-using-innovative
https://psnet.ahrq.gov/issue/error-management-lessons-aviation
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psnet.ahrq.gov/issue/evaluating-implementation-project-re-engineered-discharge-red-five-veterans-health
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 … Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons … learned from the field.
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hcup-us.ahrq.gov/datainnovations/clinicaldata/lvfeedback.jsp
February 01, 2025 - Evaluation of the LOINC Mapping Process Report ( PDF file, 141 KB; HTML ), FL Pilot project
Lessons … Learned ( HTML ), page 26, FL Pilot project
Evaluation of LOINC Mapping and Transmission of Data … Processes: Barriers and Lessons Learned ( PDF file, 2 MB; HTML ), presentation by B.
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digital.ahrq.gov/principal-investigator/mehr-david
January 01, 2023 - blood glucose and blood pressure telemonitoring in primary care practices for patients with diabetes: lessons … learned. … blood glucose and blood pressure telemonitoring in primary care practices for patients with diabetes: lessons … learned.
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psnet.ahrq.gov/issue/race-differences-malpractice-event-database-large-healthcare-system
December 15, 2021 - August 24, 2022
Lessons learned from a systems approach to engaging patients and families … July 15, 2020
Apology laws and malpractice liability: what have we learned? … June 24, 2020
Evidence that nurses need to participate in diagnosis: lessons from malpractice
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psnet.ahrq.gov/issue/description-medical-malpractice-claims-involving-advanced-practice-providers
August 19, 2020 - August 19, 2020
Lessons learned from medical malpractice claims involving critical care … September 7, 2022
Apology laws and malpractice liability: what have we learned? … June 24, 2020
Evidence that nurses need to participate in diagnosis: lessons from malpractice
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psnet.ahrq.gov/issue/rising-frequency-it-blackouts-indicates-increasing-relevance-it-emergency-concepts-ensure
October 12, 2022 - October 27, 2010
Understanding ultrarare adverse events - lessons learned from a twelve-year … November 8, 2017
Changing smart pump vendors: lessons learned.