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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case1.html
November 01, 2014 - Insights about lessons learned were gathered by asking interviewees whether and how they would change … As expected, lessons learned were closely aligned with the facilitators and barriers ( Exhibit 1.17 ) … Lessons learned referred most often to the scope, pace, and coordination of Lean activities; Lean team … learned to improve on the next Bed Flow project. … Less-than-optimal results build internal expertise and provide useful lessons to inform the execution
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
August 20, 2015 - Encourage your Team Leads to discuss actual CANDOR events to drive home important lessons.
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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.
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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.
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www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/DiagnosticSafety-flier.pdf
November 01, 2024 - Diagnostic Safety Centers of Excellence to
promote and encourage collaboration and capture and share lessons
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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.
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - Editorial Note: The physician (case submitter) further reflected on what he learned from this experience … These are the smaller lessons from this case.
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Basic assumptions and lessons distilled from the cognitive systems engineering literature (11-14) are … Overall, they highlight a number of important lessons that can be applied to health care
settings. … Assumptions and Lessons from the Literature
Assumptions Lessons
Human behavior in professional settings
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - The essential difference is that it treats the physician as the "learned intermediary" (to borrow a phrase … read aboutdiagnosis-specific knowledge on how does one investigate, how does one treat, what are the lessons … learned and recent advances. … Diagnosing diagnosis errors: Lessons from a multi-institutional collaborative project for the diagnostic
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www.ahrq.gov/sites/default/files/wysiwyg/topics/IAWG-July-2024-meeting-notes.pdf
January 01, 2024 - DLS is also partnering with VA Hospital Systems Laboratories
and sharing best practices and lessons … learned.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
March 01, 2004 - Reporting and preventing medical mishaps: Lessons from non-medical
near miss reporting systems. … were likely to have contributed to the increase in
reporting rates for ASRS during this period, the lessons … to be learned from the
example set by ASRS are clear: If you want an individual to voluntarily report … Reporting and preventing
medical mishaps: lessons from non-medical near miss
reporting systems.
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-9-appreciative-inquiry.pdf
September 01, 2015 - Ask pairs to report back to the large group what they learned from conducting the interview.
a. … What lessons did you learn about conducting an AI-focused interview?
b. What was comfortable?
c. … After all skits and drawings have been shared, ask each learner to share one lesson learned about
working … After completing the rounds, members return to their teams, discuss what they learned, talk
about the … own implementation plan, and discuss possible changes to
their plan to improve it based on what they learned
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel_facnotes.docx
December 01, 2017 - SAY:
The safety program for surgery builds on the lessons learned from previous successful statewide … And National-Level Highlights
SAY:
It also builds on the lessons learned from National On the CUSP: Stop
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/overview-fac-notes.html
December 01, 2017 - Say:
The safety program for surgery builds on the lessons learned from previous successful statewide … And National-Level Highlights
Say:
It also builds on the lessons learned from National On the CUSP
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/framework-slides/CUSP-A-Framework-for-Success-Mar-7-2012-508.ppt
January 01, 2012 - Effort
Add science of safety education to orientation
Learn from one defect per quarter; share or post lessons
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_1-introduction.pptx
July 01, 2023 - Self-directed and self-paced
Mandatory in-person team facilitation sessions
Reinforce online module lessons … and demonstration-based training, we expect you to schedule in-person team facilitation sessions so lessons
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Diagnosing diagnosis errors: Lessons from a multi-institutional collaborative project for the diagnostic … The essential difference is that it treats the physician as the "learned intermediary" (to borrow a phrase … read aboutdiagnosis-specific knowledge on how does one investigate, how does one treat, what are the lessons … learned and recent advances.
-
www.ahrq.gov/sites/default/files/publications/files/confidreportguide_1.pdf
March 01, 2016 - Performance improvement messaging for physicians: lessons from market
research* ................... … In cognitive testing, physicians are asked to tell, in their own words, what they learned from
different … As much can be learned from
implementation failures as from successes yet null findings on any topic … Data feedback efforts in quality improvement: lessons learned from US
hospitals. … Performance improvement messaging for physicians: lessons from market research*
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psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
October 28, 2020 - your initiative and its intersection with the COVID-19 response – how are you using the work and the lessons … I would encourage frontline staff in hard hit areas to use forums like that to share what they’ve learned … We are not New York, so some lessons didn’t apply. … While management of the infection has improved as the pandemic has continued and facilities have learned … Hood about Remote Patient Monitoring
March 15, 2023
The Lancet Commission on lessons
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs016130-lewis-final-report-2009.pdf
January 01, 2009 - We also learned that ED physicians were not always aware of the existence of many
of the safety net … Lessons Learned and Challenges to EHR and HIE Implementation
There was general consensus among hospitals … MCHIE_Final_
Report.pdf
“Metro DC Health Information Exchange (MeDHIX)
Characteristics, Challenges, Lessons … Learned” AHRQ 2008
Annual Conference; Thomas L. … Aim 4
Aim 5
Aim 6
Aim 7
Results
Aim 1
Aim 2
Aim 3
Aim 4
Aim 5
Aim 6
Aim 7
Lessons