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Total Results: over 10,000 records

Showing results for "learned".

3761. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74178/psn-pdf
      December 15, 2021 - Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005. December 15, 2021 Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22- 0009. https://psnet.ahrq.gov/issue/strategies-improve-patient-safe…

3762. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/856584/psn-pdf
      January 01, 2024 - Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS). November 29, 2023 Ravindran S, Matharoo M, Rutter MD, et al. Patient safety incidents in endoscopy: a human factors analysis of nonprocedural signific…

3763. Root Cause Analysis Gone Wrong | PSNet
      psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
      August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

3764. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49531/psn-pdf
      March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…

3765. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49829/psn-pdf
      May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

3766. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet
      psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
      April 26, 2023 - Researchers who have implemented surveillance monitoring systems have noted several challenges and lessons learned … By using these lessons learned, surveillance monitoring programs will be much more likely to succeed … These programs could benefit from the lessons learned in this surveillance monitoring approach.

3767. Current pulse: can a production system reduce medical errors in health care? | PSNet
      psnet.ahrq.gov/issue/current-pulse-can-production-system-reduce-medical-errors-health-care
      September 09, 2011 - Commentary Current pulse: can a production system reduce medical errors in health care? Citation Text: Printezis A, Gopalakrishnan M. Current pulse: can a production system reduce medical errors in health care? Qual Manag Health Care. 2007;16(3):226-238. Copy Citation Format: …

3768. Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes. | PSNet
      psnet.ahrq.gov/issue/organisational-readiness-exploring-preconditions-success-organisation-wide-patient-safety
      February 01, 2011 - Study Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes. Citation Text: Burnett S, Benn J, Pinto A, et al. Organisational readiness: exploring the preconditions for success in organisation-wide patient safety im…

3769. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. | PSNet
      psnet.ahrq.gov/issue/patient-and-clinician-experiences-uncertainty-diagnostic-process-current-understanding-and
      March 11, 2020 - Commentary Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions. Citation Text: Meyer AND, Giardina TD, Khawaja L, et al. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding a…

3770. Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. | PSNet
      psnet.ahrq.gov/issue/diagnostic-safety-needs-assessment-and-informed-curriculum-academic-childrens-hospital
      June 28, 2023 - Study Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. Citation Text: Congdon M, Rasooly IR, Toto RL, et al. Diagnostic safety: needs assessment and informed curriculum at an academic children's hospital. Pediatr Qual Saf. 2024;9(6):e773. do…

3771. Utilizing pharmacy students in transitions-of-care services. | PSNet
      psnet.ahrq.gov/issue/utilizing-pharmacy-students-transitions-care-services
      October 19, 2022 - Commentary Utilizing pharmacy students in transitions-of-care services. Citation Text: L'Hommedieu T, DeCoske M, Lababidi RE, et al. Utilizing pharmacy students in transitions-of-care services. Am J Health Syst Pharm. 2015;72(15):1266-8. doi:10.2146/ajhp140561. Copy Citation Format…

3772. Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. | PSNet
      psnet.ahrq.gov/issue/educational-quality-improvement-report-outcomes-revised-morbidity-and-mortality-format
      March 10, 2010 - Study Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. Citation Text: Bechtold ML, Scott SD, Nelson K, et al. Educational quality improvement report: outcomes from a revised morbidity and mortality format tha…

3773. Journey toward high reliability: a comprehensive safety program to improve quality of care and safety culture in a large, multisite radiation oncology department. | PSNet
      psnet.ahrq.gov/issue/journey-toward-high-reliability-comprehensive-safety-program-improve-quality-care-and-safety
      September 19, 2017 - Study Journey toward high reliability: a comprehensive safety program to improve quality of care and safety culture in a large, multisite radiation oncology department. Citation Text: Woodhouse KD, Volz E, Maity A, et al. Journey Toward High Reliability: A Comprehensive Safety Program to…

3774. "Plans are worthless, but planning is everything": advancing patient safety by better managing the paradox of planning versus adaptation. | PSNet
      psnet.ahrq.gov/issue/plans-are-worthless-planning-everything-advancing-patient-safety-better-managing-paradox
      September 23, 2020 - Commentary "Plans are worthless, but planning is everything": advancing patient safety by better managing the paradox of planning versus adaptation. Citation Text: Call RC, Espiritu SG, Barrows DA. “Plans are worthless, but planning is everything”: advancing patient safety by better mana…

3775. 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

3776. 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

3777. 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

3778. 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

3779. 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

3780. 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