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Showing results for "lessons learned".

3961. Types of diagnostic errors in neurological emergencies in the emergency department. | PSNet
      psnet.ahrq.gov/issue/types-diagnostic-errors-neurological-emergencies-emergency-department
      October 30, 2019 - suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons

3962. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet
      psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
      April 26, 2023 - Researchers who have implemented surveillance monitoring systems have noted several challenges and lessons … learned, the first of which is clinician pushback on surveillance alarm thresholds. … By using these lessons learned, surveillance monitoring programs will be much more likely to succeed … These programs could benefit from the lessons learned in this surveillance monitoring approach.

3963. 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

3964. 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

3965. 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.

3966. 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

3967. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846922/psn-pdf
      March 29, 2023 - Caring beyond health care: lessons learned from a community-based partnership to reduce hospital readmission

3968. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49791/psn-pdf
      April 01, 2017 - Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149:774-779.

3969. Chipra205-Materials Via (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA205-Materials_VIA.pdf
      January 01, 2010 - Implementing developmental screening and referrals: lessons learned from a national project.

3970. Chipra204-Materials Via (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/CHIPRA204-Materials_VIA.pdf
      January 01, 2010 - Implementing developmental screening and referrals: lessons learned from a national project.

3971. Improving Antibiotic Use is a Patient Safety Issue
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/implementing-stewardship-slides.pptx
      September 01, 2022 - A framework for implementing antibiotic stewardship in ambulatory care: lessons learned from the Agency

3972. Established Child Health Care Quality Measures: HEDIS | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/measures/measure-4.html
      November 01, 2017 - States and others with experience can share lessons learned and examples of progress.

3973. Enhancing Medication CPOE Safety and Quality by Indications-Based Prescribing | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/enhancing-medication-cpoe-safety-and-quality-indications-based-prescribing
      January 01, 2023 - The team used the lessons and key insights learned from the stakeholder panels to design a working prototype

3974. Implementation Guide: MRSA and SSI Prevention (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/147-implementation-guide.pdf
      April 01, 2025 - and MRSA Prevention is a guidance document that shares tips on recognizing success and sharing the lessons … learned broadly. … CUSP teams have a unique opportunity to collaborate with other departments to share the lessons learned

3975. 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.

3976. CAHPS Transcript: Strategies for Improving CAHPS Health Plan Survey Scores (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20160413/hp-survey-strategies-webcast-transcript.pdf
      April 01, 2016 - how they overcame barriers, their results, and again, I think most importantly, what are the key lessons … that they learned from these improvement activities. … Bouldin, Slide 41 So some of the ideas and key lessons learned really is about being transparent around … And then finally, in terms of specific lessons learned here, we’re talking about celebrating team successes … Well, one of the things I learned after this happened with us is that in talking with other systems about

3977. Final Progress Report: Pursuing Perfection in Pediatric Therapeutics (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/lannon2-report.pdf
      January 01, 2024 - Colletti RB, Margolis PA, Kappelman MD Development of process and outcome measures for improvement: lessons … learned in a quality improvement collaborative for pediatric inflammatory bowel disease Inflammatory … Iyer SB, Beekman RH, III, et al National pediatric cardiology quality improvement collaborative: Lessons

3978. 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.

3979. Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Quinn.pdf
      January 01, 2004 - This paper highlights the lessons learned while implementing a clinical guideline and working to promote … In this paper, we will describe the lessons learned from the implementation of a clinical guideline … Reviewing patients with intermediate or high risk factors who received perioperative beta-blocker, we learned

3980. The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meyer_41.pdf
      March 03, 2008 - program on systems adoption and meeting specific quality and safety goals, as well as the generalizable lessons … learned in the development and implementation of the program. … suggest a more firm specification beyond “enough.”25 In reviewing the program with our physicians, we learned … plan to incorporate ill e have own that collaborative design and implementation guided by the lessons … learned in the terature on incentives can strike appropriate balances to avoid the potential perverse