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Showing results for "learned".

  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865486/psn-pdf
    April 03, 2024 - Clinical informatics team members' perspectives on health information technology safety after experiential learning and safety process development: qualitative descriptive study. April 3, 2024 Recsky C, Rush KL, MacPhee M, et al. Clinical informatics team members' perspectives on health information technology saf…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34085/psn-pdf
    February 09, 2011 - Discussion of medical errors in morbidity and mortality conferences. February 9, 2011 Pierluissi E, Fischer M, Campbell AR, et al. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290(21):2838-2842. https://psnet.ahrq.gov/issue/discussion-medical-errors-morbidity-and-mortality-confer…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45074/psn-pdf
    June 01, 2016 - Post-event debriefings during neonatal care: why are we not doing them, and how can we start? June 1, 2016 Sawyer T, Loren D, Halamek LP. Post-event debriefings during neonatal care: why are we not doing them, and how can we start? J Perinatol. 2016;36(6):415-9. doi:10.1038/jp.2016.42. https://psnet.ahrq.gov/issue…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45720/psn-pdf
    April 13, 2017 - Medical morbidity and mortality conferences: past, present and future. April 13, 2017 George J. Medical morbidity and mortality conferences: past, present and future. Postgrad Med J. 2017;93(1097):148-152. doi:10.1136/postgradmedj-2016-134103. https://psnet.ahrq.gov/issue/medical-morbidity-and-mortality-conference…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40191/psn-pdf
    May 28, 2014 - The Value of Close Calls in Improving Patient Safety. May 28, 2014 Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158. https://psnet.ahrq.gov/issue/value-close-calls-improving-patient-safety Close calls (sometimes called near misses) pose unique challenges and opportunities when …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60614/psn-pdf
    June 24, 2020 - A systems approach to analyzing and preventing hospital adverse events. June 24, 2020 Leveson N, Samost A, Dekker SWA, et al. A systems approach to analyzing and preventing hospital adverse events. J Patient Saf. 2020;16(2):162-167. doi:10.1097/pts.0000000000000263. https://psnet.ahrq.gov/issue/systems-approach-an…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35896/psn-pdf
    July 23, 2010 - Work-hour restrictions as an ethical dilemma for residents. July 23, 2010 Carpenter RO, Austin MT, Tarpley JL, et al. Work-hour restrictions as an ethical dilemma for residents. Am J Surg. 2006;191(4):527-32. https://psnet.ahrq.gov/issue/work-hour-restrictions-ethical-dilemma-residents This study surveyed 170 res…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73562/psn-pdf
    August 04, 2021 - Medication safety in mental health hospitals: a mixed- methods analysis of incidents reported to the National Reporting and Learning System. August 4, 2021 Alshehri GH, Keers RN, Carson-Stevens A, et al. Medication safety in mental health hospitals: a mixed- methods analysis of incidents reported to the National R…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73141/psn-pdf
    April 14, 2021 - Investigating hospital supervision: a case study of regulatory inspectors' roles as potential co-creators of resilience. April 14, 2021 Øyri SF, Braut GS, Macrae C, et al. Investigating Hospital Supervision: A Case Study of Regulatory Inspectors’ Roles as Potential Co-creators of Resilience. J Patient Saf. 2021;17…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38569/psn-pdf
    May 20, 2009 - Reducing health care hazards: lessons from the Commercial Aviation Safety Team. May 20, 2009 Pronovost P, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial aviation safety team. Health Aff (Millwood). 2009;28(3):w479-89. doi:10.1377/hlthaff.28.3.w479. https://psnet.ahrq.gov/is…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48066/psn-pdf
    July 24, 2019 - What interventions could reduce diagnostic error in emergency departments? A review of evidence, practice and consumer perspectives. July 24, 2019 Wright B, Faulkner N, Bragge P, et al. What interventions could reduce diagnostic error in emergency departments? A review of evidence, practice and consumer perspectiv…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45594/psn-pdf
    December 19, 2017 - Teaching quality improvement and patient safety in residency education: strategies for meaningful resident quality and safety initiatives. December 19, 2017 Morrison RJ, Bowe SN, Brenner MJ. Teaching Quality Improvement and Patient Safety in Residency Education: Strategies for Meaningful Resident Quality and Safet…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851070/psn-pdf
    June 28, 2023 - Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action. June 28, 2023 Santhosh L, Cornell E, Rojas JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. AHRQ Publication No. 23-0040-1-EF. https://psnet.ahrq.gov/issue/diagnostic-s…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60050/psn-pdf
    March 18, 2020 - Zero harm in health care. March 18, 2020 Gandhi TK, Feeley D, Schummers D. Zero Harm in Health Care. NEJM Catal Innov Care Deliv. 2020;1(2). doi:10.1056/cat.19.1137. https://psnet.ahrq.gov/issue/zero-harm-health-care Health systems are encouraged to strive for zero preventable harm, but achieving this goal require…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838321/psn-pdf
    October 12, 2022 - Meeting the Moment: Addressing Barriers and Facilitating Clinical Adoption of Artificial Intelligence in Medical Diagnosis. October 12, 2022 Adler-Milstein J, Aggarwal N, Ahmed M, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2022. https://psnet.ahrq.gov/issue/meeting-moment-addressing-bar…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47980/psn-pdf
    May 01, 2019 - Intensive care medicine in 2050: preventing harm. May 1, 2019 Beet C, Benoit D, Bion J. Intensive care medicine in 2050: preventing harm. Intensive Care Med. 2019;45(4):505-507. doi:10.1007/s00134-018-5353-z. https://psnet.ahrq.gov/issue/intensive-care-medicine-2050-preventing-harm This commentary discusses curren…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73215/psn-pdf
    May 05, 2021 - To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021 Isherwood P, Waterson P. To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. J Patient Saf Risk Manag. 2021;26(2):64-73. doi:10.1177/2516043521990…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41132/psn-pdf
    March 13, 2012 - Spreading a medication administration intervention organizationwide in six hospitals. March 13, 2012 Kliger J, Singer SJ, Hoffman F, et al. Spreading a medication administration intervention organizationwide in six hospitals. Jt Comm J Qual Patient Saf. 2012;38(2):51-60. https://psnet.ahrq.gov/issue/spreading-medi…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45960/psn-pdf
    January 01, 2021 - Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care. March 15, 2017 Pfoh ER, Engineer L, Singh H, et al. Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care. J Patient Saf. 2021;17(3):e121-e127. doi:10.1097/PTS.000000…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867382/psn-pdf
    December 18, 2024 - Pharmacists’ perceptions of error reporting systems. December 18, 2024 Hartt CM, Weigand H, MacDonald AJ, et al. Pharmacists’ perceptions of error reporting systems. J Patient Saf Risk Manag. 2024;29(6):268-273. doi:10.1177/25160435241288287. https://psnet.ahrq.gov/issue/pharmacists-perceptions-error-reporting-syst…
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