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Showing results for "lessons learned".

4401. National Center for Pediatric Practice Based Research & Learning - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/p30hs021645-fiks-final-report-2018.pdf
      January 01, 2018 - Fiks A, "Spurring Adoption of Patient Portals to Collect Patient-Reported Outcomes: Lessons Learned".

4402. AHRQ EvidenceNOW: Building State Capacity: Interim Evaluation Report I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/en-bsc-interim-report-1.pdf
      January 31, 2024 - To support rural primary care practices and build on lessons learned from AHRQ’s prior EvidenceNOW initiatives … learned. … learned so far … learned. … learned so far

4403. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
      June 30, 2004 - selected reports for analysis, the results of both our quantitative and qualitative analyses, and what we learned … that collect information about medical errors so that practitioners can learn from them and apply lessons … learned to promote patient safety. … Conclusions Our mixed methods approach allowed us to efficiently and effectively extract patient safety lessons

4404. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
      May 25, 2023 - OSHA,PSOs) • Alliance providing a central repository of lessons learned, best practices, harm events

4405. A4A Combo Psi Casestudy (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a4a_combo_psi_casestudy.pdf
      June 02, 2025 - Robinson has several key lessons to share with new users to facilitate their quality improvement journey

4406. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
      November 01, 2011 - Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.

4407. Breaking Down Barriers to Aseptic Catheter Insertion (May 12, 2015) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-transcript.html
      December 01, 2017 - For those of you in the audience who are nurses, if you think about your early nursing days, when you learned … Maybe that's just one of those things that I learned in school but gee, in practice, nobody seems to … Some of the lessons learned is that the basics do need to be assessed and addressed. … As was mentioned before, most of the nurses have learned and performed this skill in a very controlled … Also, a lesson learned for us is that in both instances, the industry was very helpful in improving the

4408. Breaking-Down-Barriers-Transcript (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/breaking-down-barriers-transcript.docx
      May 12, 2015 - For those of you in the audience who are nurses, if you think about your early nursing days, when you learned … Maybe that's just one of those things that I learned in school but gee, in practice, nobody seems to … Some of the lessons learned is that the basics do need to be assessed and addressed. … As was mentioned before, most of the nurses have learned and performed this skill in a very controlled … Also, a lesson learned for us is that in both instances, the industry was very helpful in improving the

4409. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848107/psn-pdf
      April 26, 2023 - //psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned

4410. Technology as a Tool for Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
      April 26, 2023 - The authors also presented evidence that it was cost-effective and detailed implementation lessons learned

4411. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73302/psn-pdf
      May 26, 2021 - I learned root-cause analysis when I was the Director of Clinical Services at MedStar (Mobile Healthcare

4412. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/4es-early-mobility-facguide.docx
      January 01, 2017 - Slide 27 Summary ASK: What have we learned today about the Four Es of early mobility?

4413. Final Progress Report: The National Quality Forum Annual Meeting 2004 (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/kizer2-report.pdf
      January 01, 2025 - This presentation focused on the lessons learned about the need for consensus and alignment in data … Numerous lessons have been learned in the startup efforts under this new law. … These lessons include the need to protect reported data from disclosure; provide a clear understanding

4414. Using Health IT: Eight Quality Improvement Stories (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/EightSuccessStories_092810.pdf
      September 01, 2010 - learned from the program. … long-term care to improve quality and provide guidance on translating health IT implementation lessons … The team also learned that providing ongoing quality feedback is important for sustaining improvements … Selected lessons are highlighted below. 11 Cerner PowerChart® (at the hospital) and Cerner PowerChart … In establishing the HIE, member facilities and SMRTNET learned that encouraging clinicians to use the

4415. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33831/psn-pdf
      April 01, 2017 - RW: You said one of the early lessons was that you couldn't easily translate these observations from … And it goes back to the aphorism that I learned a long time ago from a very wise CIO who said, "Computers

4416. The Rural Physician Peer Review Model©: A Virtual Solution (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Williams_115.pdf
      June 19, 2008 - network in any month, new hospitals may need to learn what more experienced hospitals have already learned … Learning helpers: How they facilitated improvement and improved facilitation – lessons from a hospital-wide

4417. In Situ Simulation: Challenges and Results (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Patterson_48.pdf
      May 05, 2008 - The experiences and lessons learned during implementation of three pilot in situ programs are reviewed … Lessons learned provide guidance that is intended to increase the future success and implementation … It is one of the core skills to be learned by pediatric residents during their pediatric intensive care

4418. In Conversation With… Mark Graban, MS, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
      January 01, 2015 - I love reading Don Berwick , Lucian Leape , and others who directly worked with or learned from Dr. … You see those types of lessons visiting a Toyota plant.

4419. Issue Brief 7. Improving Education: A Key to Better Diagnostic Outcomes (pdf file)
      www.ahrq.gov/sites/default/files/publications2/files/dxsafety-issuebrief-education.pdf
      March 11, 2022 - over the past two decades have shown how diagnostic errors can be prevented or mitigated, and these lessons … diagnostic process and causes of diagnostic errors provides important insight into what should be taught, learned … The tacit lessons they learn in the chaos of the modern clinical environment likely teach students … Evidence that nurses need to participate in diagnosis: lessons from malpractice claims.

4420. Making Healthcare Safer IV Rapid Review: Examining the Impact of Implementing High-Reliability Organization Principles on Patient Safety Outcomes (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/hro-rapid-research.pdf
      May 01, 2025 - provider peer safety coaches for error prevention techniques; routine sharing of good catches and lessons … learned; and increased communication through safety huddles. … learned); providing training opportunities (e.g., enhanced root cause analysis); implementing strategies … learned by healthcare facilities which have implemented MATCH strategies. … Building cultures of high reliability: Lessons from the high reliability organization paradigm.