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Showing results for "lessons learned".

4161. 1. Background and Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/projects/state/how-to-guide/guide1.html
      August 01, 2024 - programs to disseminate and implement evidence-based guidelines to improve heart health. 8 Based on lessons

4162. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety | PSNet
      psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
      March 01, 2017 - s desire for more data was balanced with the intent to act on what they had already learned. … RW : During my training years, I learned precisely nothing about culture. … MDW : I would probably challenge you and say you learned an awful lot about culture as a medical student … So articulating that, codifying it, and saying, "Here are the lessons you can learn from the pain we … Resources From the Same Author(s) Perspective What We've Learned

4163. AHRQ PBRN IRB Tip Sheet (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/pbrn/pbrn-irb-tipsheet.pdf
      June 27, 2025 - https://www.ahrq.gov/downloads/ncepcr/communities/pbrn/learning-series/building-newer-pbrn/index.html#/lessons

4164. New Dashboard Tracks Progress Toward 50 Percent Reduction in Patient and Workforce Harm | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/941.html
      December 01, 2024 - The findings highlight the important lessons researchers are learning after the COVID-19 pandemic about

4165. Learning from AHRQ's Diagnostic Safety Culture Survey at a Tertiary Care Health System in Brazil: A Case Study (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/dx-issue-brief-20-brazil-health-system.pdf
      August 01, 2024 - on prior work on this topic.6-8 For instance, we are implementing periodic meetings to disseminate lessons … learned from diagnostic errors.

4166. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
      March 01, 2004 - Lessons learned Reporting systems such as MEDMARX can be valuable tools for collecting and managing … Implementation Perhaps the most important lessons to come out of this program have involved the implementation … Introduction The Department of Defense response Centralized reporting Results Actions taken Discussion Lessons … learned Conclusions Acknowledgments Author affiliations References Table 1.

4167. Literature Collection | The Academy
      integrationacademy.ahrq.gov/products/literature-collection
      January 01, 2025 - In this paper, I have shared lessons about developing an innovative and sustainable integrated care learning … These lessons are drawn from my experience of leading an integrated care specialisation programme (that

4168. Module 6: Sustainability: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module6/mod6-facguide.html
      March 01, 2017 - Describe lessons learned from examples of success across multiple settings. … Encourage team leaders to discuss actual resident stories to drive home important lessons.

4169. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - 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.

4170. Making Healthcare Safer IV: High Reliability Organization (HRO) as a Patient Safety Practice (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/hro-protocol.pdf
      January 01, 2023 - coach their peers in the use of error prevention techniques; routine sharing of good catches and lessons … learned; and increased communication through safety huddles. … Building cultures of high reliability: lessons from the high reliability organization paradigm.

4171. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety6.html
      September 01, 2022 - Evidence that nurses need to participate in diagnosis: lessons from malpractice claims.

4172. One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. | PSNet
      psnet.ahrq.gov/issue/one-size-fits-all-mixed-methods-evaluation-impact-100-single-room-accommodation-staff-and
      July 01, 2016 - 21, 2017 Prospects for comparing European hospitals in terms of quality and safety: lessons

4173. Association of changing hospital readmission rates with mortality rates after hospital discharge. | PSNet
      psnet.ahrq.gov/issue/association-changing-hospital-readmission-rates-mortality-rates-after-hospital-discharge
      August 20, 2018 - Understanding the factors influencing implementation of a new national patient safety policy in England: lessons

4174. The association between complications, incidents, and patient experience: retrospective linkage of routine patient experience surveys and safety data. | PSNet
      psnet.ahrq.gov/issue/association-between-complications-incidents-and-patient-experience-retrospective-linkage
      February 20, 2019 - 2019 Learning from morbidity and mortality conferences: focus and sustainability of lessons

4175. Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications. | PSNet
      psnet.ahrq.gov/issue/intended-and-unintended-effects-large-scale-adverse-event-disclosure-controlled-after
      August 18, 2021 - 2015 Disclosing large scale adverse events in the US Veterans Health Administration: lessons

4176. The relationship between patients' perception of care and measures of hospital quality and safety. | PSNet
      psnet.ahrq.gov/issue/relationship-between-patients-perception-care-and-measures-hospital-quality-and-safety
      February 13, 2019 - October 27, 2010 Tracking rates of patient safety indicators over time: lessons from

4177. Challenges and remediation for Patient Safety Indicators in the transition to ICD-10-CM. | PSNet
      psnet.ahrq.gov/issue/challenges-and-remediation-patient-safety-indicators-transition-icd-10-cm
      September 23, 2020 - April 22, 2017 Designing an abstraction instrument: lessons from efforts to validate

4178. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. | PSNet
      psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review
      July 20, 2022 - Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons

4179. Decisionmaker | Digital Healthcare Research
      digital.ahrq.gov/population/decisionmaker
      January 01, 2024 - Conference on Health IT and Analytics (CHITA) facilitates the development of research and implementation lessons

4180. Info FAQs | Agency for Healthcare Research and Quality
      www.ahrq.gov/faqs/index.html?page=4
      June 12, 2025 - Finding the True North: Lessons From the National Healthcare Quality and Disparities Report.