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Showing results for "learned".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73387/psn-pdf
    March 17, 2021 - beyond the crisis response to the pandemic, the question becomes how COVID-19 – and what has been learned

  2. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
    February 01, 2014 - Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33829/psn-pdf
    March 01, 2017 - s desire for more data was balanced with the intent to act on what they had already learned.

  4. In Conversation with…Thomas J. Nasca, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
    February 01, 2010 - I've been fortunate to have been a member of the LCME as well and to have learned that accreditation

  5. Evidence Brief: Implementation of High Reliability Organization Principles. | PSNet

    psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles
    November 11, 2020 - Book/Report Evidence Brief: Implementation of High Reliability Organization Principles. Citation Text: Evidence Brief: Implementation of High Reliability Organization Principles. Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs; May 2019. …

  6. Ethical duty of health care systems to address interfacility medical error discovery. | PSNet

    psnet.ahrq.gov/issue/ethical-duty-health-care-systems-address-interfacility-medical-error-discovery
    September 11, 2019 - Commentary Ethical duty of health care systems to address interfacility medical error discovery. Citation Text: Antunez AG, Shuman AG, Jagsi R, et al. Ethical Duty of Health Care Systems to Address Interfacility Medical Error Discovery. J Am Coll Surg. 2018;227(5):543-547. doi:10.1016/j.…

  7. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. | PSNet

    psnet.ahrq.gov/issue/applying-lean-sigma-solutions-mistake-proof-chemotherapy-preparation-process
    September 02, 2015 - Commentary Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Citation Text: Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86. Cop…

  8. Patient Safety: Achieving a New Standard of Care. | PSNet

    psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care-0
    March 29, 2007 - Book/Report Classic Patient Safety: Achieving a New Standard of Care. Citation Text: Patient Safety: Achieving a New Standard of Care. Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM, Wolcott J, Erickson SM, e…

  9. The objective impact of clinical peer review on hospital quality and safety. | PSNet

    psnet.ahrq.gov/issue/objective-impact-clinical-peer-review-hospital-quality-and-safety
    April 13, 2017 - Study The objective impact of clinical peer review on hospital quality and safety. Citation Text: Edwards MT. The objective impact of clinical peer review on hospital quality and safety. Am J Med Qual. 2011;26(2):110-9. doi:10.1177/1062860610380732. Copy Citation Format: …

  10. Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. | PSNet

    psnet.ahrq.gov/issue/position-statement-criminalization-medical-error-and-call-action-prevent-patient-harm-error
    December 02, 2020 - Organizational Policy/Guidelines Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. Citation Text: Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. Cooper J, Thomas B…

  11. User's manual for the IOM's 'Quality Chasm' report. | PSNet

    psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
    August 04, 2021 - Commentary User's manual for the IOM's 'Quality Chasm' report. Citation Text: Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote…

  12. Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs. | PSNet

    psnet.ahrq.gov/issue/coaching-debriefer-peer-coaching-improve-debriefing-quality-simulation-programs
    July 31, 2019 - Commentary Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs. Citation Text: Cheng A, Grant V, Huffman J, et al. Coaching the Debriefer: Peer Coaching to Improve Debriefing Quality in Simulation Programs. Simul Healthc. 2017;12(5):319-325. doi:10.…

  13. The debrief imperative: building teaming competencies and team effectiveness. | PSNet

    psnet.ahrq.gov/issue/debrief-imperative-building-teaming-competencies-and-team-effectiveness
    December 16, 2020 - Commentary The debrief imperative: building teaming competencies and team effectiveness. Citation Text: Tannenbaum SI, Greilich PE. The debrief imperative: building teaming competencies and team effectiveness. BMJ Qual Saf. 2023;32(3):125-128. doi:10.1136/bmjqs-2022-015259. Copy Citati…

  14. The hidden risk of wheelchair use. | PSNet

    psnet.ahrq.gov/issue/hidden-risk-wheelchair-use
    March 09, 2022 - Commentary The hidden risk of wheelchair use. Citation Text: Quesenberry M. The hidden risk of wheelchair use. Patient Safety. 2022;4(3):6-9. doi:10.33940/alert/2022.9.1. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34735/psn-pdf
    June 16, 2014 - goals to create unified reporting mechanisms, support an open learning culture, ensure that lessons learned

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45350/psn-pdf
    October 21, 2016 - This report discusses the need to ensure that lessons learned in military trauma care are acted on and

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37478/psn-pdf
    February 22, 2011 - adversedrugevent https://psnet.ahrq.gov/issue/intravenous-medication-safety-and-smart-infusion-systems-lessons-learned-and-future

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47505/psn-pdf
    March 19, 2019 - A past PSNet perspective explored insights learned from experience with the AHRQ-supported teamwork

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45490/psn-pdf
    September 01, 2018 - collaboration-regulators-support-quality-and-accountability-following-medical-errors https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34849/psn-pdf
    May 14, 2012 - improving-patient-safety-five-years-after-iom-report https://psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned
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