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Showing results for "lessons learned".

4641. Final Grant Report: Using Military & Aviation Simulation Experience to Improve Rural Obstetric Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/guise2-report.pdf
      January 01, 2024 - • The error protection mechanisms that the teams had learned were even evident in a completely new … skills, including consistent use of team language, were evident on the second visit, indicating that learned … training program designed to improve clinical teamwork and safety in obstetrics, the toolkit, and lessons … learned.

4642. AHRQ_HHS Brand_Color (doc file)
      www.ahrq.gov/sites/default/files/publications/files/execsumm-lean-redesign.docx
      March 01, 2017 - Develop and disseminate knowledge and lessons learned about what factors affect the scale-up and sustainability

4643. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care | PSNet
      psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
      September 09, 2013 - October 27, 2010 Project BOOST implementation: lessons learned.

4644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49519/psn-pdf
      September 01, 2006 - Case & Commentary: Part 3 The team subsequently learned that the night float resident had mistakenly … Handoff strategies in settings with high consequences for failure: lessons for health care operations

4645. Chapter 5. Project Findings for Goal 1 | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/delivery-initiative/ihs/chapter5.html
      December 01, 2017 - Lessons Learned and Suggestions for Data Chapter 9.

4646. Appendix B. In-Person Meetings | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ssi/ssiapb.html
      April 01, 2018 - Lessons Learned Burden of unsupported practitioner SSI surveillance Documented need for enhanced

4647. HCUP-US Methods Series
      hcup-us.ahrq.gov/reports/methods/methods.jsp
      February 01, 2025 - 01 Enhancing Clinical Information in Statewide Hospital Administrative Data: Project Summary and Lessons … Learned (PDF file, 248 KB) Report #2010-02 Population Denominator Data for Use with the

4648. WITHIN 3 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/shah.pdf
      May 29, 2025 - So, in terms of lessons learned over the -- the several years we've been doing this, I touched on this

4649. Final Revised Operations Center Operational Framework (pdf file)
      cdsic.ahrq.gov/sites/default/files/2024-02/OY1%20Operations%20Center%20Operational%20Framework.pdf
      January 01, 2024 - Committee member or Workgroup Lead on ROI for PC CDS ■ Debrief and discussion of Annual Meeting and lessons … learned ■ Potential ideas for additional work ■ Dissemination and outreach activity updates September

4650. Strategy 6F: On-Demand Advice, Diagnosis, and Treatment for Minor Health Conditions | Agency for Healthcare Research and Quality
      www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/strategy6f-ondemand.html
      April 01, 2023 - Malpractice claims in Swedish telenursing: lessons learned from interviews with telenurses and managers

4651. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
      psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
      August 01, 2009 - July 2, 2019 The safety journal: lessons learned with an error reporting tool to stimulate

4652. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
      psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
      September 25, 2019 - July 19, 2023 Rooting an error review process in just culture: lessons learned.

4653. A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
      June 11, 2003 - ultimate goal was to uncover real and potential problems at an earlier stage so that appropriate lessons … can be learned and corrective actions taken.

4654. In Conversation With… Susan Haas, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
      March 01, 2019 - tangibly now that would be different than you would have done a couple of years ago based on what you've learned … networks can communicate across their systems with relative ease, hopefully sharing best practices and lessons … learned from within the system itself.

4655. Aviation Safety Methods: Quickly Adopted but Questions Remain | PSNet
      psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
      January 01, 2006 - RW: How has your training program evolved and what lessons have you learned as you've actually gone … Certainly there are some technical things that could be learned, but because of the current state of

4656. Quality Improvement in Action Facilitator Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/qi-action-notes.docx
      April 01, 2022 - Thus, beginning the planning phase again, with what has been learned from the first cycle, to continually … The “act” phase is a chance to consider all lessons learned and to think about how to make the desired

4657. Building a Safety Program in a Vast Health Care Network | PSNet
      psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
      March 01, 2019 - networks can communicate across their systems with relative ease, hopefully sharing best practices and lessons … learned from within the system itself. … tangibly now that would be different than you would have done a couple of years ago based on what you've learned

4658. Improving Quality through Decision Support for Evidence-Based Pharmacotherapy (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017072-lobach-final-report-2011.pdf
      January 01, 2011 - the qualitative analysis with 28 regard to the third possible point of failure, we also learned … Lessons Learned. … We have learned several valuable lessons through the development, implementation and operational support … As a second lesson, we learned that conventional technologies of facsimile and email, while ubiquitous

4659. Cognitive Overload in the ICU | PSNet
      psnet.ahrq.gov/web-mm/cognitive-overload-icu
      June 01, 2005 - overwhelmed as the sole recipient of the cognitive load in such environments.( 14 ) There are also lessons

4660. Rural Community Partnerships—EMR Implementation Project (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015302-mullen-final-report-2008.pdf
      January 01, 2008 - The lesson learned with Physician Center was to have the scanning solution in place doing back scanning … It kept me ahead of what was being learned about the basics of EMR and allowed me to advance in the