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Showing results for "lessons learned".

4501. Using Electronic Records to Detect and Learn from Ambulatory Diagnostic Errors (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017244-thomas-final-report-2010.pdf
      January 01, 2010 - Diagnosing diagnosis errors: Lessons from a multi-institutional collaborative project.

4502. VHA’s National Falls Collaborative and Prevention Programs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stalhandske2_70.pdf
      March 01, 2006 - The Falls Toolkit consolidates lessons learned from the Falls Collaborative and from current research

4503. 4. How Do We Implement Best Practices in Our Organization? (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
      October 01, 2014 - Didactic methods can include a variety of formats, such as lectures, interactive presentations, online lessons

4504. 4. How Do We Implement Best Practices in Our Organization? (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
      October 01, 2014 - Didactic methods can include a variety of formats, such as lectures, interactive presentations, online lessons

4505. Static Teach-back Interactive Module (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/teachback-module-accessible.pdf
      January 01, 2013 - Static Teach-back Interactive Module Teach-back 1. Title Teach-Back Improving Patient Safety by Engaging Patients and Families in Effective Clinician- Patient Communication 1 Teach-back Interactive Module 2. AHRQ Sponsored by the Agency for Healthcare Research and Quality (AHRQ), this tea…

4506. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
      May 01, 2017 - Observations from 450 shoulder dystocia simulations: lessons for skills training.

4507. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership.pdf
      June 03, 2021 - These lessons tell us that healthcare leaders need to play an essential role in preventing diagnostic

4508. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership-cx.pdf
      June 03, 2021 - These lessons tell us that healthcare leaders need to play an essential role in preventing diagnostic

4509. The Evolution of Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/evolution-root-cause-analysis
      February 26, 2025 - Ochsner’s Chief Quality Officer learned about RCA 2 during a conference and was so impacted that we … We learned from other organizations that those are not sustainable actions. … Sarah Mossburg: What are the main lessons you have learned from years of completing RCAs and RCA 2 ?

4510. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
      February 26, 2025 - Ochsner’s Chief Quality Officer learned about RCA 2 during a conference and was so impacted that we … We learned from other organizations that those are not sustainable actions. … Sarah Mossburg: What are the main lessons you have learned from years of completing RCAs and RCA 2 ?

4511. Patient Safety During Hospital Discharge | PSNet
      psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
      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

4512. Innovations in Promoting Hand Hygiene Compliance | PSNet
      psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
      May 01, 2014 - RW : What have we learned about the use of bigger sticks that might be either public reporting (beyond … RW : What lessons from hand hygiene are relevant to trying to increase compliance with other safety practices … What we learned with hand hygiene was that system change was a definite prerequisite to the success of … What we learned from our experience is now spreading all over the world.

4513. In Conversation With… Didier Pittet, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
      May 01, 2014 - RW : What have we learned about the use of bigger sticks that might be either public reporting (beyond … RW : What lessons from hand hygiene are relevant to trying to increase compliance with other safety practices … What we learned with hand hygiene was that system change was a definite prerequisite to the success of … What we learned from our experience is now spreading all over the world.

4514. Final Progress Report: Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization (pdf file)
      www.ahrq.gov/sites/default/files/2025-04/marin-report.pdf
      January 01, 2025 - Generation of evidence and translation into practice: lessons learned and future directions. … Generation of evidence and translation into practice: lessons learned and future directions.

4515. Venous Thromboembolism Safety Toolkit: A Systems Approach to 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-Zierler_81.pdf
      September 01, 2008 - Phase II products will consist of implementation strategies (based on lessons learned) and the two interventions … Phase II will add a package of implementation strategies based on our lessons learned and the evaluation

4516. Improving Adolescent Primary Care Through An Interactive Behavioral Health Module - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs020997-ozer-final-report-2014.pdf
      January 01, 2014 - with different emphases (e.g. mental health, substance use, violence, obesity, etc.) to build off lessons … learned from development of these colleagues’ instruments. … Strategic dissemination of this exploratory and developmental health IT project will enable us to share lessons … learned from the development and pilot implementation of the module to inform more comprehensive health

4517. Standardization and Automatic Extraction of Quality Measures in an Ambulatory EHR (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017094-mccolm-final-report-2009.pdf
      January 01, 2009 - List of Publications and Products “Capturing PQRI Data: Lessons Learned from an AHRQ Grant” Online … “Selecting PQRI Indicators: Lessons Learned from an AHRQ Grant” Online presentation by Anita Karcz

4518. Cardio-HIT Phase II - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017160-kmetik-final-report-2009.pdf
      January 01, 2009 - Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA Performance … Publications Reporting on National Clinical Performance Measures from Ambulatory Electronic Health Records: Lessons … Learned from the Cardio-HIT Project (Phase I) Reporting Cardiovascular Performance Measures from

4519. Amendment_HIE-Protocol_3-14-2015 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/health-information-exchange_research-protocol.pdf
      April 20, 2015 - Retrospective: lessons learned from the Santa Barbara project and their implications for health information … Synthesis of Lessons Learned in the First 5 Years of State and Regional Demonstration Health Information

4520. Provider- and Practice-Level Competencies for Integrated Behavioral Health in Primary Care: A Literature Review (pdf file)
      integrationacademy.ahrq.gov/sites/default/files/2020-06/AHRQ_AcadLitReview.pdf
      January 01, 2020 - Behavioral health consultation and primary care: lessons learned. … Behavioral health consultation and primary care: lessons learned.