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Showing results for "lessons learned".

4301. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33828/psn-pdf
      March 01, 2017 - 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

4302. Sustainability Module: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/fac-notes.html
      October 01, 2020 - Several critical success factors are required to sustain the interventions learned and continued gains … Encourage team leaders to discuss actual patient stories to drive home important lessons. … The following examples will provide “lessons learned” to assist in sustainability in your facility.

4303. Enabling E-Prescribing and Enhanced Management of Controlled Medications - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017157-carrow-final-report-2012.pdf
      January 01, 2012 - It was subsequently learned that the Transaction Control Reference Number, which was not required by … With the lessons learned, the project is therefore proposing additional areas of study may exist with … learned for prescriber and pharmacy software system vendors, providers, pharmacies, PMPs, and regulators … The lessons learned from this project may influence how quickly these implementations occur. … The findings of this study provide important lessons to those implementing EPCS in the community, but

4304. 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.

4305. 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

4306. 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

4307. 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

4308. 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.

4309. 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

4310. Create Operational System Support Integration | The Academy
      integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan/establish-operational-systems-support-integration
      January 01, 2022 - Integrating Behavioral and Physical Health Care in the Real World: Early Lessons … from Advancing Care Together This article presents implementation challenges and lessons learned

4311. 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

4312. 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.

4313. 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.

4314. 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

4315. 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

4316. 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.

4317. 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…

4318. 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

4319. 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

4320. EvidenceNOW Publications | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/projects/heart-health/research-results/results/publications.html
      May 01, 2024 - Reveals Sizable Data Inaccuracies in Small Primary Care Practices The Midwest Cooperative reflected on lessons … learned from EvidenceNOW using interviews from practice leaders and practice facilitators from practices … Lessons learned from this project will guide future strategies for D&I of evidence-based practices in … The role of health extension in practice transformation and community health improvement: Lessons from … learned from EvidenceNOW.