Results

Total Results: over 10,000 records

Showing results for "learned".

181. Analyzing and discussing human factors affecting surgical patient safety using innovative technology: creating a safer operating culture. | PSNet
     psnet.ahrq.gov/issue/analyzing-and-discussing-human-factors-affecting-surgical-patient-safety-using-innovative
     August 25, 2021 - Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of … View More Related Resources Understanding ultrarare adverse events - lessons learned

182. Using smart IV infusion pumps outside of patient rooms. | PSNet
     psnet.ahrq.gov/issue/using-smart-iv-infusion-pumps-outside-patient-rooms
     September 23, 2020 - Challenges, facilitators, and lessons learned are discussed. … February 24, 2021 Intravenous medication safety and smart infusion systems: lessons learned

183. Spotlight Series | PSNet
     psnet.ahrq.gov/issue/all-one-and-one-all-how-patient-safety-starts-healthcare-workers
     August 24, 2022 - June 21, 2023 Lessons Learned about Human Fallibility, System Design, and Justice in … September 14, 2018 A Hospital Accident: Lessons Learned – A Death, A Conviction, and

184. How hospitals select their patient safety priorities: an exploratory study of four Veterans Health Administration hospitals. | PSNet
     psnet.ahrq.gov/issue/how-hospitals-select-their-patient-safety-priorities-exploratory-study-four-veterans-health
     March 15, 2016 - Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons learned … December 15, 2011 Quality improvement lessons learned from National Implementation of … November 25, 2020 Sharing lessons learned to prevent adverse events in anesthesiology

185. A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and its meetings. | PSNet
     psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its
     March 04, 2015 - describes one hospital's experience implementing  Failure Mode and Effects Analysis and highlights lessons learned … April 28, 2021 Shaping systems for better behavioral choices: lessons learned from a

186. Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change. | PSNet
     psnet.ahrq.gov/issue/department-veterans-affairs-chief-resident-quality-and-patient-safety-program-model-spread
     September 05, 2018 - September 5, 2018 Wrong-side thoracentesis: lessons learned from root cause analysis. … July 16, 2015 Sharing lessons learned to prevent incorrect surgery. … Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned

187. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47059/psn-pdf
     May 16, 2018 - Participating in a multisite study exploring operational failures encountered by frontline nurses: lessons learned … Participating in a Multisite Study Exploring Operational Failures Encountered by Frontline Nurses: Lessons Learned

188. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46543/psn-pdf
     July 11, 2018 - A PSNet perspective assessed lessons learned about electronic health record safety. … reasons-computerised-provider-order-entry-cpoe-based-inpatient-medication-ordering-errors https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned

189. Anesthesia Patient Safety Foundation Newsletter. | PSNet
     psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-newsletter
     August 14, 2019 - U.S. compounding pharmacy-related outbreaks, 2001--2013: public health and patient safety lessons learned … 1, 2017 The evolution of the Anesthesia Patient Safety Movement in America: lessons learned

190. Consumer Guide to Adverse Health Events. | PSNet
     psnet.ahrq.gov/issue/consumer-guide-adverse-health-events
     June 04, 2024 - June 4, 2024 Adverse Health Care Events Reporting System: What Have We Learned? … U.S. compounding pharmacy-related outbreaks, 2001--2013: public health and patient safety lessons learned

191. Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit. | PSNet
     psnet.ahrq.gov/issue/computerized-provider-order-entry-implementation-no-association-increased-mortality-rates
     November 16, 2022 - The authors noted that the lessons learned from the initial implementation problems were essential to … July 3, 2016 Project BOOST implementation: lessons learned.

192. What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness. | PSNet
     psnet.ahrq.gov/issue/what-do-we-really-know-about-crew-resource-management-healthcare-umbrella-review-crew
     September 29, 2021 - for future research to expand beyond acute care and to investigate the sustainability of lessons learned … View More Related Resources Understanding ultrarare adverse events - lessons learned

193. Latent risk assessment tool for health care leaders. | PSNet
     psnet.ahrq.gov/issue/latent-risk-assessment-tool-health-care-leaders
     September 05, 2018 - The authors outline results and lessons learned from implementing the tool. … September 7, 2016 Five years after 'To Err is Human': what have we learned?

194. Chief resident for quality improvement and patient safety: a description. | PSNet
     psnet.ahrq.gov/issue/chief-resident-quality-improvement-and-patient-safety-description
     July 02, 2014 - commentary relates how two organizations implemented this strategy along with challenges and lessons learned … January 15, 2014 Developing a quality and safety curriculum for fellows: lessons learned

195. The safe day call: reducing silos in health care through frontline risk assessment. | PSNet
     psnet.ahrq.gov/issue/safe-day-call-reducing-silos-health-care-through-frontline-risk-assessment
     May 25, 2016 - The authors review the results and lessons learned in the 4 years following the intervention. … October 1, 2014 Project BOOST implementation: lessons learned.

196. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. | PSNet
     psnet.ahrq.gov/issue/national-trauma-care-system-integrating-military-and-civilian-trauma-systems-achieve-zero
     September 12, 2018 - This report discusses the need to ensure that lessons learned in military trauma care are acted on … May 12, 2021 Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis.

197. Retained guidewires in the Veterans Health Administration: getting to the root of the problem. | PSNet
     psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem
     March 13, 2013 - Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned … April 12, 2019 Sharing lessons learned to prevent adverse events in anesthesiology nationwide … November 18, 2009 Sharing lessons learned to prevent incorrect surgery.

198. Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training. | PSNet
     psnet.ahrq.gov/issue/surgical-programs-veterans-health-administration-maintain-briefing-and-debriefing-following
     October 24, 2018 - July 16, 2015 Sharing lessons learned to prevent incorrect surgery. … Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned … March 25, 2020 Wrong-side thoracentesis: lessons learned from root cause analysis.

199. The safety journal: lessons learned with an error reporting tool to stimulate systems thinking. | PSNet
     psnet.ahrq.gov/issue/safety-journal-lessons-learned-error-reporting-tool-stimulate-systems-thinking
     January 21, 2019 - Study The safety journal: lessons learned with an error reporting tool to stimulate

200. The Good, The Bad, and The Ugly: Patient Experiences with CRPs. | PSNet
     psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps
     February 28, 2024 - September 7, 2022 Lessons Learned about Human Fallibility, System Design, and Justice … June 26, 2019 A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing