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Showing results for "lessons learned".

3861. Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula | PSNet
      psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
      February 01, 2019 - We have learned that creating such a transparent and just culture does not automatically result from … conducive environment to not only teach the foundations of health systems science, but to reinforce these lessons … March 20, 2019 The safety journal: lessons learned with an error reporting tool to stimulate

3862. Module 8: Organizational Learning and Sustainability | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
      August 01, 2022 - Encourage your Team Leads to discuss actual CANDOR events to drive home important lessons.

3863. The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm | PSNet
      psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
      February 26, 2025 - Critical Radiology Alert Process October 30, 2024 Quality improvement lessons … learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation

3864. Appendix 1-A. Suggested Slides for Module 1 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod1a.html
      October 01, 2014 - Slide 6 Key Lessons Learn to notice a change early.

3865. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care | PSNet
      psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
      January 01, 2015 - I love reading Don Berwick , Lucian Leape , and others who directly worked with or learned from Dr. … You see those types of lessons visiting a Toyota plant. … Perspective African Partnerships for Patient Safety: Lessons … Learned December 1, 2014 Interview In Conversation

3866. Final Progress Report: Acute Care Learning Laboratory - Reducing Threats to Diagnostic Fidelity in Critical Illness (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/pickering-report.pdf
      January 01, 2025 - performance interventions in clinical practice, facilitate preliminary effectiveness studies, and capture lessons … learned from resultant work system reorganization. 7 List of Publications and Products 1. … Diagnosing Diagnosis Errors: Lessons from a Multi- institutional Collaborative Project.

3867. Final Progress report: Creating High Reliability Organizations (pdf file)
      www.ahrq.gov/sites/default/files/2024-03/small-report.pdf
      January 01, 2024 - selected for its generalizability, compelling theoretical framework, and strategy of translating lessons … February, Chicago, Illinois Training for the Unexpected: Leading Healthcare to a New Level of Safety: Lessons … Integration into an Organizational Safety Program The Roles of Leadership, Cultures of Safety, and Lessons

3868. 099-Cusp-Guide-Why-Choose-Cusp-Approach (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/099-cusp-guide-why-choose-cusp-approach.docx
      October 01, 2024 - also improve the work settings of other similar areas in the facility facing similar issues when the lessons … learned are shared.

3869. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
      April 21, 2008 - To the extent that what is being learned in sensemaking is integrated with our reporting efforts, it … Defining and classifying medical error: Lessons for learning. … Defining and classifying medical error: Lessons from patient safety reporting systems.

3870. In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO | PSNet
      psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
      January 12, 2022 - also hosted Safe Table discussions, where members of the PSO share COVID-19-related safety issues and lessons … learned in a protected, safe environment. … an event analysis, we held Safe Table discussions and invited providers to come with what they had learned … KH: What have you learned about the impact of COVID-19 on patient safety? … We learned that PPE hinders communication.

3871. Patient Advocacy in Patient Safety: Have Things Changed? | PSNet
      psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
      June 01, 2014 - Robert Wachter, Editor, AHRQ WebM&M : What have you learned since you entered the world of medicine and … I learned that if you understand structural thinking—if you understand feedback loops and the cultural … Another aspect arose when I learned about the Institute of Medicine's Best Care at Lower Cost report … Perspective African Partnerships for Patient Safety: Lessons … Learned December 1, 2014 Perspective Overuse

3872. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
      January 12, 2022 - also hosted Safe Table discussions, where members of the PSO share COVID-19-related safety issues and lessons … learned in a protected, safe environment. … an event analysis, we held Safe Table discussions and invited providers to come with what they had learned … KH: What have you learned about the impact of COVID-19 on patient safety? … We learned that PPE hinders communication.

3873. Healthcare Systems and Infrastructure | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2025-annual-report/healthcare-systems.html
      August 01, 2025 - of  AHRQ’s EvidenceNOW: Building State Capacity grantees, the guide includes effective approaches, lessons … learned, and example materials.

3874. Final Progress Report: Process Reliability and Organizational Learning in Home Health Care (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
      January 01, 2025 - • Based on lessons learned through intervention implementation, develop and disseminate toolkits that … It builds upon lessons learned in Module I.

3875. AHRQ EvidenceNOW: Building State Capacity: Interim Evaluation Report II (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/en-bsc-interim-report-2.pdf
      July 01, 2024 - We outline several lessons learned below. … learned … They also have biweekly meetings with all PFs to receive continuous training and share lessons learned … We outline several lessons learned below. … What lessons were learned?

3876. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49699/psn-pdf
      February 01, 2014 - Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. … Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

3877. AHRQ National Webinar on Artificial Intelligence Tools to Improve Provider Effectiveness and Patient Outcomes – Questions and Answers (pdf file)
      digital.ahrq.gov/sites/default/files/docs/artificial-intelligence-tools-improve-qa-03182025.pdf
      March 18, 2025 - Real-Time Predictive Monitoring in Acute Care Cardiology Trial (PM-IMPACCT) QUESTION: What are some lessons … learned from implementing the CoMET system and integrating it into the workflow? … ANSWER: So, I have alluded to some of the lessons learned, particularly around methodological considerations

3878. DEcIDE DRN Report 2 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/distributed-network-proof_research.pdf
      June 01, 2010 - Lessons learned from this proof-of-principle demonstration include the likely success of an incremental … Based on the lessons learned from this proof-of-principle demonstration, an incremental approach to

3879. In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
      August 01, 2016 - We think the principle of patient safety must be learned at the beginning of health education. … 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.

3880. Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes | PSNet
      psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
      July 23, 2024 - 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 … Lessons from a series of research on teamwork, leadership and team training.