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Showing results for "lessons learned".

1161. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34735/psn-pdf
      June 16, 2014 - set of goals to create unified reporting mechanisms, support an open learning culture, ensure that lessons … learned are applied and changes made, and to more broadly embrace the systems approach to minimize

1162. How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. | PSNet
      psnet.ahrq.gov/issue/how-do-hospital-boards-govern-quality-improvement-mixed-methods-study-15-organisations
      February 20, 2019 - 20, 2019 Prospects for comparing European hospitals in terms of quality and safety: lessons … June 25, 2014 Governing patient safety: lessons learned from a mixed methods evaluation … Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons

1163. Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service. | PSNet
      psnet.ahrq.gov/issue/explaining-organisational-responses-board-level-quality-improvement-intervention-findings
      November 21, 2017 - 21, 2017 Prospects for comparing European hospitals in terms of quality and safety: lessons … June 25, 2014 Governing patient safety: lessons learned from a mixed methods evaluation … Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons

1164. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33613/psn-pdf
      May 01, 2005 - As Duke physicians, nurses, and hospital leaders tried to find meaningful lessons in the aftermath of … near misses are openly identified, reviewed, and responded to in a manner that allows us to share lessons … learned. … This is truly unfortunate, since it is both wrong and short sighted: the lessons learned from catastrophic

1165. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837852/psn-pdf
      August 17, 2022 - neuroradiology-diagnostic-errors-tertiary-academic-centre-effect-participation-tumour-boards https://psnet.ahrq.gov/issue/eight-ct-lessons-we-learned-hard-way-analysis-current-patterns-radiological-error-and

1166. Outcome of 6 years of protocol use for preventing wrong site office surgery. | PSNet
      psnet.ahrq.gov/issue/outcome-6-years-protocol-use-preventing-wrong-site-office-surgery
      February 10, 2012 - August 19, 2009 Adverse event reporting: lessons learned from 4 years of Florida office … September 14, 2022 How doctors think: common diagnostic errors in clinical judgment--lessons

1167. Theorizing about systems: an ecological task for patient safety research. | PSNet
      psnet.ahrq.gov/issue/theorizing-about-systems-ecological-task-patient-safety-research
      August 20, 2008 - Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons … October 27, 2010 Patient safety: lessons learned.

1168. Pediatric emergency nurses self-reported medication safety practices. | PSNet
      psnet.ahrq.gov/issue/pediatric-emergency-nurses-self-reported-medication-safety-practices
      March 03, 2019 - Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons … August 4, 2010 Lessons learned: basic evidence-based advice for preventing medication

1169. Briefings, checklists, geese, and surgical safety. | PSNet
      psnet.ahrq.gov/issue/briefings-checklists-geese-and-surgical-safety
      August 02, 2015 - Lessons from aviation to improve patient safety. … May 20, 2015 Sharing lessons learned to prevent incorrect surgery.

1170. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38976/psn-pdf
      October 07, 2009 - psnet.ahrq.gov/issue/radiology-errors-are-we-learning-our-mistakes https://psnet.ahrq.gov/issue/eight-ct-lessons-we-learned-hard-way-analysis-current-patterns-radiological-error-and

1171. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33612/psn-pdf
      May 01, 2005 - Saul Weingart, Director of the Center for Patient Safety at DFCI, to reflect on the lessons of the past … First, we learned that safety–if it was to be a core property of our system of care rather than an empty … Fourth, we learned that we could not do this work alone. … Sixth, and most important, we learned that the work of creating safe care is never finished. … required tenacity among our leaders and the courage to face our own failures in order to learn the lessons

1172. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45754/psn-pdf
      September 01, 2018 - This editorial describes lessons learned from the Massachusetts PROMISES (Proactive Reduction of Outpatient

1173. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42011/psn-pdf
      March 06, 2013 - This article describes the iterative process and lessons learned by a university medical center during

1174. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41703/psn-pdf
      November 08, 2012 - tell-truth-ethical-and-practical-issues-disclosing-medical-mistakes-patients https://psnet.ahrq.gov/issue/shaping-systems-better-behavioral-choices-lessons-learned-fatal-medication-error

1175. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33615/psn-pdf
      June 01, 2005 - Are there lessons there for other institutions? PP: There were a number of important factors. … What lessons from your experience with Hopkins are generalizable? … PP: One of the lessons in overseeing quality and safety at Hopkins is that our center could never be … We have learned there were many ways of identifying defects: M&M conferences, incident-reporting systems … Yet we also learned that despite all this, we often fail to learn from these defects; mistakes recur

1176. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73887/psn-pdf
      September 29, 2021 - psnet.ahrq.gov/issue/body-ct-technical-advances-improving-safety https://psnet.ahrq.gov/issue/eight-ct-lessons-we-learned-hard-way-analysis-current-patterns-radiological-error-and

1177. Have we gone too far in translating ideas from aviation to patient safety? | PSNet
      psnet.ahrq.gov/issue/have-we-gone-too-far-translating-ideas-aviation-patient-safety
      March 06, 2005 - March 6, 2005 Escape Fire: Lessons for the Future of Health Care. … Improving Diagnostic Safety and Quality April 26, 2023 What went right: lessons … July 21, 2010 What have we learned about interventions to reduce medical errors?

1178. Person-Centered Guidelines for Preserving Family Presence in Challenging Times. | PSNet
      psnet.ahrq.gov/issue/person-centered-guidelines-preserving-family-presence-challenging-times
      October 14, 2015 - October 14, 2015 Eight CT lessons that we learned the hard way: an analysis of current … September 24, 2018 View More Related Resources Lessons from the

1179. Legislative Report to the General Assembly: Adverse Event Reporting. | PSNet
      psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting
      May 20, 2009 - Copy Citation Related Resources From the Same Author(s) Eight CT lessons … that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with … December 6, 2017 Adverse Health Care Events Reporting System: What Have We Learned?

1180. Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries. | PSNet
      psnet.ahrq.gov/issue/structural-and-organizational-issues-patient-safety-comparison-health-care-other-high-hazard
      February 09, 2011 - July 14, 2010 Escape Fire: Lessons for the Future of Health Care. … July 26, 2011 Risk mitigation in large scale systems: lessons from high reliability organizations … June 16, 2011 What have we learned about interventions to reduce medical errors?