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Showing results for "lessons learned".

4661. Near Miss with Bedside Medications | PSNet
      psnet.ahrq.gov/web-mm/near-miss-bedside-medications
      February 01, 2006 - They are free lessons about how things go wrong and how they can be fixed before someone gets hurt. … Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.

4662. Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Gururaja_7.pdf
      January 24, 2008 - point of care.4 Background The development of teamwork skills has become recognized as a set of learned … examples of teamwork competencies using their clinical experience • Apply teamwork competencies learned … The complexity of team training: What we have learned from aviation and its application to medicine

4663. Spreading Lean: Taking Efficiency Interventions in Health Services Delivery to Scale - Executive Summary (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/execsumm-lean-redesign.pdf
      March 01, 2017 - Develop and disseminate knowledge and lessons learned about what factors affect the scale-up and sustainability

4664. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33785/psn-pdf
      May 01, 2015 - At least for that subset of surgeons, they learned exactly where they stood against their peers. … RW: Are there lessons from other fields with similar attributes?

4665. Operations Center: Operational Framework – Option Year 2 (pdf file)
      cdsic.ahrq.gov/sites/default/files/2025-03/Operations%20Center%20OY2%20Operational%20Framework_508.pdf
      January 01, 2025 - July 23, 2025 ■ Debrief and discussion of Annual Meeting and lessons learned ■ Potential ideas for

4666. Operations Center: Operational Framework – Option Year 2 (pdf file)
      digital.ahrq.gov/sites/default/files/Operations%20Center%20OY2%20Operational%20Framework_508.pdf
      September 17, 2025 - July 23, 2025 ■ Debrief and discussion of Annual Meeting and lessons learned ■ Potential ideas for

4667. VisualDecisionLinc: Real-Time Decision Support for Behavioral Health - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs019023-mane-final-report-2014.pdf
      January 01, 2014 - Lessons learned from the initial UI evaluation were used to make changes the UI. 5.19.

4668. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72835/psn-pdf
      March 10, 2021 - KH: What are some of the lessons that you’ve learned from your work in inpatient and outpatient settings

4669. Final Progress Report: The Institute for the Design of Environments Aligned for Patient Safety (IDEA4PS) (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/mcalearney-report.pdf
      January 01, 2024 - “Lessons about Adoption of Healthcare Innovations.” … Building Human Factors Capabilities Within a Hospital System: Lessons Learned.

4670. 157-What-Are-4-Es (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/157-what-are-4-es.docx
      October 01, 2024 - Lessons learned from the high performing units should be shared with units whose performance was less

4671. Optimizing Health and Function as We Age: Roundtable Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/healthy-aging-roundtable.pdf
      September 08, 2022 - These results are communicated to the entire team and lessons learned can be discussed and applied to … Often, these lessons have less to do with the solution itself 16 and more to do with the dynamics

4672. Privacy or Safety? | PSNet
      psnet.ahrq.gov/web-mm/privacy-or-safety
      December 01, 2011 - Key lessons to consider include: Review your HIPAA and state medical privacy law policies to ensure

4673. Final Progress Report: Detecting, Assessing, and Learning from Patient-Perceived Breakdowns in Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/mazor-report.pdf
      January 01, 2024 - program was ultimately disseminated across all 10 MSH hospitals, incorporating enhancements based on lessons … learned during Aim 1, and adaptations to take into account the specific culture, context and constraints … Based on what we learned during piloting, we went on to implement two alternative versions of the

4674. Methods (continued, 2) | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3a.html
      July 01, 2018 - Generally, the evidence in this section represents lessons learned from literature on organizational

4675. Enhanced Functionality for the Distributed Research Network Pilot (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/distributed-network-expansion_research.pdf
      April 01, 2012 - ................................................................................................17 Lessons … Learned in Development and Implementation .......................................................... … Our approach was based on lessons learned from Phase 1 of DRN and specifically on our findings that … learned from the project and the anticipated next steps in the upcoming DRN version. … Lessons Learned in Development and Implementation The activities involved in the technical development

4676. 4. Assessment of the Intervention (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreen4a.html
      April 01, 2018 - In addition, based on lessons learned from the pilot, we disseminated a packet of information to office … However, we learned that the office manager did not always distribute this information to others in the

4677. Strategy 2: Communicating to Improve Quality (Implementation Handbook) (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Implement_Hndbook_508.docx
      April 30, 2013 - After identifying lessons learned from the single-unit implementation, you can refine your approach and … Recognize that communication is a skill that can be taught and learned but not without continual feedback

4678. Physician and Physician Practice Research Database Feasibility Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/data/3P-RD-Feasibility-Report.pdf
      February 01, 2024 - It provides a high-level discussion on what was done, insights and lessons learned from implementing … Based on the lessons learned from the 3P-RD, future work should focus on continuing to build out knowledge … Future work should build on lessons learned during the prototype phase, prioritizing a revisit of the … Drawing from lessons learned during the prototype, we recommend the following areas for consideration

4679. Safety Culture in EMS | PSNet
      psnet.ahrq.gov/perspective/safety-culture-ems
      May 26, 2021 - I learned root-cause analysis when I was the Director of Clinical Services at MedStar (Mobile Healthcare

4680. In Conversation With... Chris Cebollero, BS, CCEMT-P | PSNet
      psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p
      May 26, 2021 - I learned root-cause analysis when I was the Director of Clinical Services at MedStar (Mobile Healthcare