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Showing results for "lessons learned".

4461. 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.

4462. 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.

4463. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49872/psn-pdf
      August 08, 2019 - Diagnosising diagnosis errors: lessons from a multi-institutional collaborative project.

4464. 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.

4465. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
      January 01, 2022 - Version 0.1 of the CFER-DS, which incorporated what was learned from usability testing, was reviewed … Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project.

4466. Microsoft PowerPoint - Health IT Implementation.ppt (pdf file)
      digital.ahrq.gov/sites/default/files/docs/medicaid/health-it-implementation.pdf
      December 01, 2005 - sponsors) that you are making a difference and that your voice counts in policy issues – To share lessons … learned with others doing the same thing across the country – For future funding and sustainability … Advancing Excellence in Health Care Cleveland Clinic Many “lessons learned” – Implemented CPOE in a

4467. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
      January 01, 2004 - An important lesson learned from this near miss was that a lack of a reliable research-participant tracking … Based on lessons learned from this debriefing, a clinical research sign-out system is being developed … Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.

4468. In Conversation With... Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
      December 22, 2020 - One of the things we learned from a culture survey we did was that the two areas that we were particularly … The difference between medical and dental school that I learned when I came into the school is that the … Lessons learned from dental patient safety care reports.

4469. In Conversation With… Mary Dixon-Woods, DPhil | PSNet
      psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
      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 … s desire for more data was balanced with the intent to act on what they had already learned.

4470. In Conversation With… Harlan Krumholz, MD, SM | PSNet
      psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
      April 01, 2018 - themes of the last 20 years of improvement work has been unanticipated consequences, and we've now learned … RW : As a learning health system, what do you think the lessons are from readmission penalties? … What have we learned from that measure that is generalizable to our efforts to change the payment and … willing to work together and could collectively achieve a gain, then they could disseminate what they learned

4471. Adverse Events in Dentistry | PSNet
      psnet.ahrq.gov/perspective/adverse-events-dentistry
      December 22, 2020 - Lessons learned from dental patient safety care reports. … One of the things we learned from a culture survey we did was that the two areas that we were particularly … The difference between medical and dental school that I learned when I came into the school is that the

4472. Options for Developing a Web-Based Forum on Patient Registries (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/registries-forums_research_0.pdf
      May 01, 2014 - , where invited speakers from existing Web-based forums and CoPs discussed the concept of CoPs and lessons … learned from their experience managing CoPs and Web-based forums. … The CoP helps members “create self-representation” by deriving lessons and finding ways to represent … learned • Legal and regulatory issues • Informed consent (e.g., for those with disabilities) • Data … 11:15-11:30 am Break 11:30 am-12:30 pm Lessons from Existing Web-based Forums Presenters: - Margaret

4473. The Patient Safety Education Project: An international Collaboration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Emanuel_19.pdf
      February 20, 2008 - teamwork and communication, variations in health literacy among patients, a culture of blame that buries lessons … learned, and others. … structured so that course attendees can return to their home institutions to teach others what they have learned … essential knowledge about patient safety, and it brings them up to speed with regard to what has been learned

4474. Information Technology Systems for Rural Indian Health Care: Implementation and Use of a Commercial Ambulatory Care Electronic Health Record - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015339-aranaydo-final-report-2007.pdf
      January 01, 2007 - In this report we summarize the participants, tasks completed, the challenges encountered and the lessons … learned in introducing a commercial ambulatory EHR into various THP. … Substantial challenges were encountered, and the lessons learned fall into three general categories: … What was learned was to create more time and resources in an already underfunded clinic system to focus … The THP have learned that EHR implementation actually never ends as software and clinic flow adjustments

4475. Small and Rural and Critical Access Hospitals (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
      April 01, 2013 - I know we’ve had several hospitals do that, and they’ve learned it hasn’t been an implementation issue … And then once you’ve indentified a defect, then you share and post lessons that you’ve learned. … So even within your hospital, if you’ve piloted something on one unit, you want to share the lessons … learned throughout the hospital. … I think from Denise and Lorna we learned about the fundamentals of CUSP.

4476. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
      August 01, 2022 - project culminated in an SDM train-the-trainer toolkit that integrates the processes developed and lessons … learned. … The researchers also learned through the project that the taxonomy used to classify errors could be streamlined … Implementing near-miss reporting and improvement tracking in primary care practices: Lessons learned. … There will be efforts to use what was learned to improve the claims reporting system, further the development

4477. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Johnson_90.pdf
      June 10, 2008 - On error management: Lessons learned from aviation. Br Med J 2000; 320: 781-785. 2.

4478. Tacit Handover, Overt Mishap | PSNet
      psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
      August 01, 2006 - The Commentary While there is something to be learned about the proper care of spinal catheters from … Handoff strategies in settings with high consequences for failure: lessons for health care operations

4479. Production Pressures | PSNet
      psnet.ahrq.gov/web-mm/production-pressures
      November 16, 2022 - Usability of a human factors-based clinical decision support in the emergency department: lessons … learned for design and implementation.

4480. Good Catch in the Operating Room | PSNet
      psnet.ahrq.gov/web-mm/good-catch-operating-room
      August 27, 2017 - Spine Surgery February 28, 2024 Understanding ultrarare adverse events - lessons … learned from a twelve-year review of intraoperative deaths at an academic medical center.