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Showing results for "learned".

8421. Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. | PSNet
      psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident
      March 11, 2020 - Study Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident investigations: a semi-quantitative and qualitative study of factors leading to the successful implementation of recommendations. Citation Text: Wrigstad J, Bergström J, Gusta…

8422. Cost–benefit analysis of a support program for nursing staff. | PSNet
      psnet.ahrq.gov/issue/cost-benefit-analysis-support-program-nursing-staff
      October 26, 2016 - Study Classic Cost–benefit analysis of a support program for nursing staff. Citation Text: Moran D, Wu AW, Connors C, et al. Cost-Benefit Analysis of a Support Program for Nursing Staff. J Patient Saf. 2020;16(4):e250-e254. doi:10.1097/pts.0000000000000376. Co…

8423. To Err Is Human: Building a Safer Health System. | PSNet
      psnet.ahrq.gov/issue/err-human-building-safer-health-system
      July 08, 2016 - Book/Report Classic To Err Is Human: Building a Safer Health System. Citation Text: To Err Is Human: Building a Safer Health System. Kohn KT, Corrigan JM, Donaldson MS, eds. Washington, DC: Committee on Quality Health Care in America, Institute of Medicine: Nati…

8424. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. | PSNet
      psnet.ahrq.gov/issue/application-digital-quality-measure-cancer-diagnosis-epic-cosmos
      November 13, 2024 - Study Application of a digital quality measure for cancer diagnosis in Epic Cosmos. Citation Text: Zimolzak AJ, Khan SP, Singh H, et al. Application of a digital quality measure for cancer diagnosis in Epic Cosmos. J Am Med Inform Assoc. 2025;32(1):227-229. doi:10.1093/jamia/ocae253. C…

8425. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. | PSNet
      psnet.ahrq.gov/issue/defining-critical-role-nurses-diagnostic-error-prevention-conceptual-framework-and-call
      October 28, 2020 - Review Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. Citation Text: Gleason KT, Davidson PM, Tanner EK, et al. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to act…

8426. Encouraging patients to speak up about problems in cancer care. | PSNet
      psnet.ahrq.gov/issue/encouraging-patients-speak-about-problems-cancer-care
      March 11, 2013 - Study Encouraging patients to speak up about problems in cancer care. Citation Text: Mazor KM, Kamineni A, Roblin DW, et al. Encouraging patients to speak up about problems in cancer care. J Patient Saf. 2021;17(8):e1278-e1284. doi:10.1097/pts.0000000000000510. Copy Citation Format…

8427. Adverse-event-reporting practices by US hospitals: results of a national survey. | PSNet
      psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey
      December 30, 2014 - Study Adverse-event-reporting practices by US hospitals: results of a national survey. Citation Text: Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care. 2008;17(6):416-23. doi:10.1136/qshc.20…

8428. Effectiveness and efficiency of root cause analysis in medicine. | PSNet
      psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine
      July 11, 2012 - Commentary Classic Effectiveness and efficiency of root cause analysis in medicine. Citation Text: Wu AW. Effectiveness and Efficiency of Root Cause Analysis in Medicine. JAMA. 2008;299(6):685-687. doi:10.1001/jama.299.6.685. Copy Citation Format: …

8429. Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. | PSNet
      psnet.ahrq.gov/issue/nurses-perspectives-impact-management-approaches-blame-culture-health-care-organizations
      September 02, 2020 - Study Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. Citation Text: Okpala P. Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. Int J Healthc Manage. 2020;13(sup1)…

8430. Medication errors among adults and children with cancer in the outpatient setting. | PSNet
      psnet.ahrq.gov/issue/medication-errors-among-adults-and-children-cancer-outpatient-setting
      January 16, 2010 - Study Medication errors among adults and children with cancer in the outpatient setting. Citation Text: Walsh KE, Dodd KS, Seetharaman K, et al. Medication errors among adults and children with cancer in the outpatient setting. J Clin Oncol. 2009;27(6):891-6. doi:10.1200/JCO.2008.18.60…

8431. Measuring harm in health care: optimizing adverse event review. | PSNet
      psnet.ahrq.gov/issue/measuring-harm-health-care-optimizing-adverse-event-review
      May 15, 2013 - Study Measuring harm in health care: optimizing adverse event review. Citation Text: Walsh KE, Harik P, Mazor KM, et al. Measuring Harm in Health Care: Optimizing Adverse Event Review. Med Care. 2017;55(4):436-441. doi:10.1097/MLR.0000000000000679. Copy Citation Format: DOI…

8432. Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education. | PSNet
      psnet.ahrq.gov/issue/root-cause-analysis-and-actions-prevention-medical-errors-quality-improvement-and-resident
      October 19, 2016 - Commentary Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education. Citation Text: Charles R, Hood B, DeRosier JM, et al. Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Educat…

8433. Improving the quality of insulin prescribing for people with diabetes being discharged from hospital | PSNet
      psnet.ahrq.gov/issue/improving-quality-insulin-prescribing-people-diabetes-being-discharged-hospital
      November 16, 2022 - Journal Article Improving the quality of insulin prescribing for people with diabetes being discharged from hospital Citation Text: Bain A, Silcock J, Kavanagh S, et al. Improving the quality of insulin prescribing for people with diabetes being discharged from hospital. BMJ Open Qual. 2…

8434. Triggers contributing to health care clinicians' disruptive behaviors. | PSNet
      psnet.ahrq.gov/issue/triggers-contributing-health-care-clinicians-disruptive-behaviors
      June 24, 2020 - Study Triggers contributing to health care clinicians' disruptive behaviors. Citation Text: Bae S-H, Dang D, Karlowicz KA, et al. Triggers contributing to health care clinicians' disruptive behaviors. J Patient Saf. 2020;16(3):e148-e155. doi:10.1097/pts.0000000000000288. Copy Citation …

8435. Long-term care nurses' experiences with patient safety incident management: a qualitative study. | PSNet
      psnet.ahrq.gov/issue/long-term-care-nurses-experiences-patient-safety-incident-management-qualitative-study
      March 24, 2021 - Study Long-term care nurses' experiences with patient safety incident management: a qualitative study. Citation Text: Serre N, Espin S, Indar A, et al. Long-term care nurses' experiences with patient safety incident management: a qualitative study. J Nurs Care Qual. 2022;37(2):188-194. d…

8436. Safety and risk management interventions in hospitals: a systematic review of the literature. | PSNet
      psnet.ahrq.gov/issue/safety-and-risk-management-interventions-hospitals-systematic-review-literature
      April 01, 2010 - Review Safety and risk management interventions in hospitals: a systematic review of the literature. Citation Text: Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):…

8437. The quest to eliminate intrathecal vincristine errors: a 40-year journey. | PSNet
      psnet.ahrq.gov/issue/quest-eliminate-intrathecal-vincristine-errors-40-year-journey
      September 15, 2010 - Commentary The quest to eliminate intrathecal vincristine errors: a 40-year journey. Citation Text: Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf Health Care. 2010;19(4):323-326. doi:10.1136/qshc.2008.030874. Copy Citation …

8438. An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting. | PSNet
      psnet.ahrq.gov/issue/analysis-structure-and-content-dashboards-used-monitor-patient-safety-inpatient-setting
      March 09, 2022 - Study An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting. Citation Text: Kuznetsova M, Frits ML, Dulgarian S, et al. An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.…

8439. A comprehensive departmental care review model: requirements, structure, and flow. | PSNet
      psnet.ahrq.gov/issue/comprehensive-departmental-care-review-model-requirements-structure-and-flow
      July 06, 2022 - Commentary A comprehensive departmental care review model: requirements, structure, and flow. Citation Text: Nestler DM, Laack TA, Scanlan-Hanson L, et al. A comprehensive departmental care review model: requirements, structure, and flow. Jt Comm J Qual Patient Saf. 2021;47(8):503-509. d…

8440. The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis. | PSNet
      psnet.ahrq.gov/issue/enabling-enacting-and-elaborating-factors-safety-culture-associated-patient-safety-multilevel
      September 21, 2022 - Study The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis. Citation Text: Lee SE, Dahinten VS. The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis. J Nu…