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digital.ahrq.gov/ahrq-funded-projects/machine-learning-health-system-integrate-care-substance-misuse-and-hiv-treatment-and-prevention/final-report
January 01, 2023 - A Machine Learning Health System to Integrate Care for Substance Misuse and HIV Treatment and Prevention Among Hospitalized Patients - Final Report
Citation
Held M., Thompson H. A Machine Learning Health System to Integrate Care for Substance Misuse and HIV Treatment and Prevention Among Hospitalized …
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psnet.ahrq.gov/node/47375/psn-pdf
November 02, 2018 - Ethical duty of health care systems to address interfacility
medical error discovery.
November 2, 2018
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.jamcollsurg.2018.08.184.
https://psn…
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psnet.ahrq.gov/node/838193/psn-pdf
September 28, 2022 - Economics of Medication Safety. Improving Medication
Safety Through Collective, Real-time Learning.
September 28, 2022
de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.
…
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psnet.ahrq.gov/node/47429/psn-pdf
December 05, 2018 - The Fearless Organization: Creating Psychological Safety
in the Workplace for Learning, Innovation, and Growth.
December 5, 2018
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
https://psnet.ahrq.gov/issue/fearless-organization-creating-psychological-safety-workplace-learning-
innova…
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psnet.ahrq.gov/node/839315/psn-pdf
January 01, 2024 - Six major steps to make investigations of suicide valuable
for learning and prevention.
November 2, 2022
Fröding E, Vincent C, Andersson-Gäre B, et al. Six major steps to make investigations of suicide valuable
for learning and prevention. Arch Suicide Res. 2024;28(1):1-19. doi:10.1080/13811118.2022.2133652.
https…
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psnet.ahrq.gov/node/837901/psn-pdf
August 24, 2022 - Trial and error: learning from malpractice claims in
childhood surgery.
August 24, 2022
Prieto JM, Falcone B, Greenberg P, et al. Trial and error: learning from malpractice claims in childhood
surgery. J Surg Res. 2022;279:84-88. doi:10.1016/j.jss.2022.05.033.
https://psnet.ahrq.gov/issue/trial-and-error-learning-…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/system/pfcasestudies/ncahec.pdf
August 01, 2014 - didactic sessions,
since each regional team leads at least one session each year and shares
lessons learned … Lessons learned
Training has grown in diversity and scope along with the program.
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psnet.ahrq.gov/node/36421/psn-pdf
August 05, 2008 - what-pilots-can-teach-hospitals-about-patient-safety
This article discusses lessons the airline industry has learned
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psnet.ahrq.gov/node/36067/psn-pdf
September 28, 2010 - a postoperative debriefing tool used by surgical teams at Johns Hopkins Hospital and
share lessons learned
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psnet.ahrq.gov/issue/provider-perspectives-partnering-parents-hospitalized-children-improve-safety
November 30, 2016 - Participating in a multisite study exploring operational failures encountered by frontline nurses: lessons learned … February 2, 2011
Lessons learned for reducing the negative impact of adverse events on
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psnet.ahrq.gov/issue/liability-impact-hospitalist-model-care
July 09, 2018 - July 9, 2018
Apology laws and malpractice liability: what have we learned? … July 14, 2010
Hospitalists as Emerging Leaders in Patient Safety: lessons learned and
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psnet.ahrq.gov/issue/digital-health-and-patient-safety
September 01, 2016 - May 4, 2022
Lessons learned implementing a complex and innovative patient safety learning … January 10, 2018
Changing smart pump vendors: lessons learned.
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psnet.ahrq.gov/issue/adverse-events-hospitals-patients-point-view
December 29, 2014 - April 12, 2019
Lessons learned for reducing the negative impact of adverse events on … December 29, 2014
Communication-and-resolution programs: the challenges and lessons learned
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psnet.ahrq.gov/issue/predictors-successful-implementation-preoperative-briefings-and-postoperative-debriefings
December 21, 2014 - July 16, 2015
Sharing lessons learned to prevent incorrect surgery. … Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned
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psnet.ahrq.gov/issue/patient-safety-objective-structured-clinical-examination
October 06, 2011 - Citation
Related Resources From the Same Author(s)
The safety journal: lessons learned … November 2, 2011
The safety journal: lessons learned with an error reporting tool to
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psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-community-settings
April 25, 2016 - April 25, 2016
Wrong-side thoracentesis: lessons learned from root cause analysis. … Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons learned
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psnet.ahrq.gov/issue/medical-professional-liability-insurance-and-its-relation-medical-error-and-healthcare-risk
December 21, 2014 - December 4, 2019
What have we learned about interventions to reduce medical errors? … November 13, 2019
Lessons learned from implementing a principled approach to resolution
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psnet.ahrq.gov/issue/clinical-alarms-improving-efficiency-and-effectiveness
February 22, 2010 - November 3, 2021
Intravenous medication safety and smart infusion systems: lessons learned … October 19, 2022
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Related Resources
Lessons learned from
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psnet.ahrq.gov/issue/national-efforts-improve-health-information-system-safety-canada-united-states-america-and
July 14, 2009 - March 9, 2011
What have we learned about interventions to reduce medical errors? … April 1, 2010
Adopting electronic medical records in primary care: lessons learned from
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psnet.ahrq.gov/node/35932/psn-pdf
October 03, 2017 - authors discuss a high-profile clinical trial incident and how transparency and sharing of lessons
learned