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Showing results for "learned".

5701. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/863222/psn-pdf
      February 28, 2024 - Systematic review of morbidity and mortality meeting standardization: does it lead to improved professional development, system improvements, clinician engagement, and enhanced patient safety culture? February 28, 2024 Steel EJ, Janda M, Jamali S, et al. Systematic review of morbidity and mortality meeting standar…

5702. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36102/psn-pdf
      March 04, 2011 - Struggling to invent high-reliability organizations in health care settings: insights from the field. March 4, 2011 Dixon NM, Shofer M. Struggling to invent high-reliability organizations in health care settings: Insights from the field. Health Serv Res. 2006;41(4 Pt 2):1618-32. https://psnet.ahrq.gov/issue/strugg…

5703. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60869/psn-pdf
      September 02, 2020 - A systematic review of trauma crew resource management training: what can the United States and the United Kingdom learn from each other? September 2, 2020 Ashcroft J, Wilkinson A, Khan M. A systematic review of trauma crew resource management training: what can the United States and the United Kingdom learn from …

5704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866351/psn-pdf
      July 24, 2024 - Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports. July 24, 2024 Leon C, Hogan H, Jani YH. Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports. Int J Qual Health Care. 2024;36(3):mzae057. doi:10.1…

5705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47535/psn-pdf
      November 07, 2018 - Gosport War Memorial Hospital. The Report of the Gosport Independent Panel. November 7, 2018 Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062. https://psnet.ahrq.gov/issue/gosport-war-memorial-hospital-report-gosport-independent-panel Organizational culture influences how comf…

5706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72658/psn-pdf
      January 20, 2021 - “I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error. January 20, 2021 Kandasamy S, Vanstone M, Colvin E, et al. “I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error. J Eval Clin Pract. 2021;27(2):236-245. doi:10.1111/jep.1353…

5707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861763/psn-pdf
      January 31, 2024 - The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis. January 31, 2024 Haylor H, Sparkes T, Armitage G, et al. The process and perspective of serious incident investigations in adult community mental health services: integrative …

5708. Physician Use of Hand-held Computers for Drug Information and Prescribing (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Galt.pdf
      January 01, 2004 - Physician Use of Hand-held Computers for Drug Information and Prescribing 93 Physician Use of Hand-held Computers for Drug Information and Prescribing Kimberly A. Galt, Mark V. Siracuse, Ann M. Rule, Bartholomew E. Clark, Wendy Taylor Abstract The purpose of this study was to develop and pilot-test an ins…

5709. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 1: Why Patient Narratives Matter (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
      July 01, 2023 - eliciting diagnostic experiences can be adapted to ensure greater consistency in how and how much can be learned

5710. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
      psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
      September 24, 2024 - Then we learned that there are specific things you can do to prevent it: elevate the head of the bed,

5711. Final Progress Report: Failure To Rescue-Patient Safety Learning Lab (FTR-PSLL) (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/blike-report.pdf
      January 01, 2025 - Gravio GD, Patriarca R: Safety Performance of Complex Systems: Lesson Learned from ATM Resilience Analysis

5712. Designing Consumer Health IT: A Guide for Developers and Systems Designers (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/developmentmethodsguide.pdf
      September 01, 2012 - Available at: http://www.healthit.ahrq.gov/ developmentmethodsbackgroundreport Applying Lessons Learned

5713. Designing Consumer Health IT: A Guide for Developers and Systems Designers (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/designing-consumer-health-it-a-guide-for-developers-and-systems-designers.pdf
      September 01, 2012 - Available at: http://www.healthit.ahrq.gov/ developmentmethodsbackgroundreport Applying Lessons Learned

5714. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training | PSNet
      psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
      February 28, 2024 - Stephen Hines: One thing that we learned is that people loved the TeamSTEPPS content but had challenges

5715. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Johnson_90.pdf
      June 10, 2008 - On error management: Lessons learned from aviation. Br Med J 2000; 320: 781-785. 2.

5716. The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Jones_29.pdf
      February 23, 2008 - Association and the national Quality Improvement Organization Support Center to disseminate lessons learned

5717. Engage the Team and Applying CUSP in the ICU Setting Slides (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
      April 01, 2022 - Engage the Team and Applying CUSP in the ICU Setting Slides CUSP Module: Engaging the Team and Applying CUSP in the ICU Setting Facilitator Guide Slide Number and Image This module, titled “Engaging the Team and Applying CUSP in the ICU Setting” is part of the Agency for Healthcare Research and Quality, or AHRQ…

5718. Identification of Patients with Low Life Expectancy - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r01hs024090-turchin-final-report-2019.pdf
      January 01, 2019 - Identification of Patients with Low Life Expectancy - Final Report FINAL PROGRESS REPORT Identification of Patients with Low Life Expectancy Principal Investigator Alexander Turchin, MD, MS1,2 Team M…

5719. The CAHPS Ambulatory Care Improvement Guide: Ways to Approach the Quality Improvement Process (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/4-approach-qi-process/cahps-section-4-ways-to-approach-qi-process.pdf
      May 17, 2017 - Some health plans, for example, have learned how to improve their call center operations by sending

5720. Prologue -- Blueprints for Action (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield1.pdf
      January 01, 1999 - of effectiveness is established in some of the papers but not in others, where more remains to be learned