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Showing results for "lessons learned".

4261. Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
      January 01, 2024 - debriefing interview by a member of the research team, exploring the realism of the simulation and lessons … learned by the participants. … of debriefings At the end of each simulation, the participants were interviewed to identify overall lessons … learned, attitudes about team disclosure, and their response to the disclosure coaching. … learned.

4262. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33820/psn-pdf
      December 01, 2016 - We spoke with him about the RCA2 report and what we have learned about root cause analysis in health … RW: What do you think the lessons of the last 15 or so years have been as we've tried to apply this

4263. TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-King_1.pdf
      April 07, 2008 - It is based on lessons learned, DoD experience, the literature of quality and patient safety, and culture … A sharing of success stories and lessons learned related to implementation strategies occurs during … these early adaptors implement, test, and refine the program, there is anticipation that much will be learned

4264. In Conversation With… Urmimala Sarkar, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
      August 22, 2014 - RW : Are there any other differences that make it hazardous to extrapolate things we've learned from … being partly we've never had the organizational model, partly finances, partly because physicians never learned … RW : You mentioned that some lessons from other industries that seem to be at least somewhat useful in … Are there lessons from other industries that do translate very well to the ambulatory side? … Safety in the Outpatient Setting While much of our progress will come from adapting the things we have learned

4265. Issue Brief 26: Exploration of Foundational Terminology and Paradigms for Improving Diagnosis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-terminology.pdf
      April 01, 2025 - align to create vulnerable moments of risk. 6 At their onset, patient safety efforts took lessons … We have learned a lot from pioneering work on patient surveys and interviews.44-47 Rather than speak … Investigators have learned that patient experience is best understood using narrative and open- ended … Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. … Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

4266. Design and Testing of a Mobile Cardiovascular Risk Service with Patient Partners - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs023952-chrischilles-final-report-2018.pdf
      January 01, 2018 - Primary lessons included numerous early navigation issues to correct and the need to incorporate active … test Discussion and Conclusions As a result of our participatory design and usability testing, we learned … We have developed a mobile app-enabled centralized pharmacist CVRS based on the lessons learned in the … Results confirm that it was able to be delivered, and we learned that pharmacists and patients wanted … Design Lessons for Older Adult Personal Health Records Software from Older Adults.

4267. Improving the Measurement of Surgical Site Infection Risk Stratification and Outcome Detection
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/ssi/ssiapu.pptx
      September 18, 2011 - have prevented a false negative was in clinical notes HHSA-290-2006-00020 ACTION task order #8 Lessons … Learned Common electronic data markers of infection are not informative enough Variation in practice … of Procedures; Postop Admission; Preop Hematocrit HHSA-290-2006-00020 ACTION task order #8 Lessons

4268. CAUTI Sustainability: Embedding CAUTI Policies, Using Data to Monitor Proress and Hardwiring CUSP Principles | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-transcript.html
      December 01, 2017 - Our learning objective for today are to examine the key lessons learned at sustaining the gain. … Other lessons learned. Ensure administration is aware of your efforts and your results. … That's not the way I learned. That's not how we ought to be doing that. … Study, you compare the data and summarize what is learned. … Even our assistant staff, the nurse tech and patient care assistant learned the maintenance bundle care

4269. How Does Infection Prevention Fit Into a Safety Program? | PSNet
      psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
      March 01, 2014 - is worth reflecting on the growth and development of such programs; this history may hold important lessons … What are a few lessons that people in the infection world have learned that might be relevant to patient … Why do you think that difference arose, and are lessons about how the infection world collects evidence

4270. In Conversation With… Alison Holmes, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
      March 01, 2014 - What are a few lessons that people in the infection world have learned that might be relevant to patient … Why do you think that difference arose, and are lessons about how the infection world collects evidence … is worth reflecting on the growth and development of such programs; this history may hold important lessons

4271. Additional TeamSTEPPS Resources | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/evidence-base/additional.html
      June 01, 2023 - Communication science lessons for patient safety and quality care.

4272. EvidenceNow Executive Summary - Virginia Cooperative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-va.pdf
      November 01, 2017 - EvidenceNow Executive Summary - Virginia Cooperative Virginia Cooperative Virginia EvidenceNOW: Advancing Heart Health in Primary Care is an initiative of the Agency for Healthcare Research and Quality (AHRQ) to transform health care delivery by building a critical infrastructure to help smaller primary ca…

4273. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33796/psn-pdf
      January 01, 2016 - MG: We didn't know either, but after a few calls to the Institute of Medicine we learned. … Also I'm a huge fan of the AHRQ WebM&M conferences, and there are many, many valuable lessons in there … What I've learned is that IOM reports tend to stay at a very high level, and it's up to the stakeholders

4274. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
      January 01, 2014 - Lessons learned from the analysis of collected event reports by PSOs can be used to educate members

4275. Dangerous Shift | PSNet
      psnet.ahrq.gov/web-mm/dangerous-shift
      July 24, 2013 - 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

4276. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841566/psn-pdf
      December 14, 2022 - However, we all know that healthcare requires data which is timely and interoperable; we certainly learned … establishing the systems of safety and those key tools of high-reliability organizations that we have learned … There are many lessons here, including communication strategies, culture, leadership, teamwork training

4277. Title Page (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015270-hayden-final-report-2008.pdf
      January 01, 2008 - Lessons learned include the importance of understanding and considering organizational structure and … We have learned that in both the pre- and post- eMAR systems, nurses would often make corrections on … We learned that the software did not provide enough patient-specific information to ever tell us. … Additional Lessons Learned. … past four years, and through our study of staff attitudes toward patient safety, there are several lessons

4278. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33638/psn-pdf
      August 01, 2006 - I learned an important lesson: enlightened, risk-taking leadership is the only way to achieve significant

4279. Final Progress Report: Caregiver innovations to reduce harm in Neonatal Intensive Care (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/thomas-report.pdf
      January 01, 2025 - Our results highlight several key findings that we learned by running scenarios that examined various … First, we learned that a policy increasing parental involvement in QI efforts as well as a policy focused … obtained by members of the PSLL to document outcomes of parent engagement processes, outcomes, and lessons … learned. … counselor Discussion As we evaluated our work over these past few years, we recognized several lessons

4280. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846563/psn-pdf
      March 21, 2023 - Lessons learned from adverse events could help improve future patient safety.