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Total Results: 3,237 records

Showing results for "lessons learned".

161. Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training. | PSNet
     psnet.ahrq.gov/issue/surgical-programs-veterans-health-administration-maintain-briefing-and-debriefing-following
     October 24, 2018 - July 16, 2015 Sharing lessons learned to prevent incorrect surgery. … Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons … learned. … March 25, 2020 Wrong-side thoracentesis: lessons learned from root cause analysis.

162. A mixed methods study exploring patient safety culture at 4 VHA Hospitals. | PSNet
     psnet.ahrq.gov/issue/mixed-methods-study-exploring-patient-safety-culture-4-vha-hospitals
     September 25, 2019 - Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons … learned from the field. … December 19, 2014 Quality improvement lessons learned from National Implementation of … April 12, 2023 Lessons learned from the RaDonda Vaught ruling.

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45706/psn-pdf
     September 01, 2018 - improving-communication-and-resolution-following-adverse-events-using-patient-created https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters … liability-claims-and-costs-and-after-implementation-medical-error-disclosure-program https://psnet.ahrq.gov/issue/implementing-hospital-based-communication-and-resolution-programs-lessons-learned-new-york

164. Retained guidewires in the Veterans Health Administration: getting to the root of the problem. | PSNet
     psnet.ahrq.gov/issue/retained-guidewires-veterans-health-administration-getting-root-problem
     March 13, 2013 - Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons … learned. … April 12, 2019 Sharing lessons learned to prevent adverse events in anesthesiology nationwide … November 18, 2009 Sharing lessons learned to prevent incorrect surgery. … 2017 Disclosing large scale adverse events in the US Veterans Health Administration: lessons

165. Using smart IV infusion pumps outside of patient rooms. | PSNet
     psnet.ahrq.gov/issue/using-smart-iv-infusion-pumps-outside-patient-rooms
     September 23, 2020 - Challenges, facilitators, and lessons learned are discussed. … February 24, 2021 Intravenous medication safety and smart infusion systems: lessons learned … Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons

166. Chief resident for quality improvement and patient safety: a description. | PSNet
     psnet.ahrq.gov/issue/chief-resident-quality-improvement-and-patient-safety-description
     July 02, 2014 - , this commentary relates how two organizations implemented this strategy along with challenges and lessons … learned. … July 2, 2014 Building a safer foundation: the Lessons Learnt patient safety training … January 15, 2014 Developing a quality and safety curriculum for fellows: lessons learned

167. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
     October 24, 2018 - July 16, 2015 Sharing lessons learned to prevent incorrect surgery. … Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons … learned. … April 25, 2016 Wrong-side thoracentesis: lessons learned from root cause analysis.

168. Department of Veterans Affairs Chief Resident in Quality and Patient Safety Program: a model to spread change. | PSNet
     psnet.ahrq.gov/issue/department-veterans-affairs-chief-resident-quality-and-patient-safety-program-model-spread
     September 05, 2018 - September 5, 2018 Wrong-side thoracentesis: lessons learned from root cause analysis. … July 16, 2015 Sharing lessons learned to prevent incorrect surgery. … Anesthesia adverse events voluntarily reported in the Veterans Health Administration and lessons … learned.

169. Patient Safety Culture: Theory, Methods and Application. | PSNet
     psnet.ahrq.gov/issue/patient-safety-culture-theory-methods-and-application
     August 24, 2016 - industries , key concepts involved such as behavior change, measurement and assessment processes, and lessons … learned from application and practice. … July 19, 2024 Improving Healthcare Team Communication: Building on Lessons from Aviation … May 8, 2013 What have we learned about interventions to reduce medical errors?

170. Diversion is a Threat to Patient Safety: Adopting Best Practices. | PSNet
     psnet.ahrq.gov/issue/diversion-threat-patient-safety-adopting-best-practices
     April 20, 2022 - February 23, 2022 Lessons Learned about Human Fallibility, System Design, and Justice … October 5, 2022 Lessons Learned about Human Fallibility, System Design, and Justice in … June 24, 2020 Medication Safety During the COVID-19 Pandemic: What Have We Learned in

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41988/psn-pdf
     January 23, 2013 - What a new doctor learned about medical mistakes from her Mom's death. January 23, 2013 Allen M. …   https://psnet.ahrq.gov/issue/what-new-doctor-learned-about-medical-mistakes-her-moms-death This … article reveals lessons a medical student learned about patient safety while dealing with errors that … https://psnet.ahrq.gov/issue/what-new-doctor-learned-about-medical-mistakes-her-moms-death

172. How hospitals select their patient safety priorities: an exploratory study of four Veterans Health Administration hospitals. | PSNet
     psnet.ahrq.gov/issue/how-hospitals-select-their-patient-safety-priorities-exploratory-study-four-veterans-health
     March 15, 2016 - Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons … learned from the field. … December 15, 2011 Quality improvement lessons learned from National Implementation of … November 25, 2020 Sharing lessons learned to prevent adverse events in anesthesiology

173. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43521/psn-pdf
     November 05, 2014 - From Science to Implementation: AHRQ's Program to Prevent HAIs—Results and Lessons. … https://psnet.ahrq.gov/issue/science-implementation-ahrqs-program-prevent-hais-results-and-lessons This … https://psnet.ahrq.gov/issue/science-implementation-ahrqs-program-prevent-hais-results-and-lessons https … ://psnet.ahrq.gov/issue/preventing-healthcare-associated-infections-results-and-lessons-learned-ahrqs-hai-program

174. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45037/psn-pdf
     February 15, 2017 - Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses … Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses … https://psnet.ahrq.gov/issue/disclosing-large-scale-adverse-events-us-veterans-health-administration- lessons-media … health system, media reports did not convey specific aspects of error disclosure, such as apologies and lessons … learned.

175. 2012 ISMP International Medication Safety Self Assessment for Oncology. | PSNet
     psnet.ahrq.gov/issue/2012-ismp-international-medication-safety-self-assessment-oncology
     January 26, 2023 - February 18, 2014 Medication Safety During the COVID-19 Pandemic: What Have We Learned … May 24, 2015 Lessons Learned about Human Fallibility, System Design, and Justice in the … Related Resources Fluorouracil error ends tragically, but application of lessons … learned will save lives.

176. The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure. | PSNet
     psnet.ahrq.gov/issue/cost-quality-academic-health-centers-annual-costs-its-quality-and-patient-safety
     October 14, 2020 - July 6, 2022 Lessons learned from a systems approach to engaging patients and families … February 15, 2023 Support opportunities for second victims lessons learned: a qualitative … January 29, 2018 Lessons learned for reducing the negative impact of adverse events on

177. Curriculum development and implementation of a national interprofessional fellowship in patient safety. | PSNet
     psnet.ahrq.gov/issue/curriculum-development-and-implementation-national-interprofessional-fellowship-patient
     November 18, 2016 - November 18, 2016 Wrong-side thoracentesis: lessons learned from root cause analysis. … July 16, 2015 Sharing lessons learned to prevent incorrect surgery. … A guide to evaluation of quality improvement and patient safety educational programs: lessons … November 5, 2014 Case-based learning for patient safety: the Lessons Learnt program for

178. Spotlight Series | PSNet
     psnet.ahrq.gov/issue/all-one-and-one-all-how-patient-safety-starts-healthcare-workers
     August 24, 2022 - June 21, 2023 Lessons Learned about Human Fallibility, System Design, and Justice in … September 14, 2018 A Hospital Accident: Lessons Learned – A Death, A Conviction, and

179. Injury to research volunteers—the clinical-research nightmare. | PSNet
     psnet.ahrq.gov/issue/injury-research-volunteers-clinical-research-nightmare
     December 19, 2017 - The authors discuss a high-profile clinical trial incident and how transparency and sharing of lessons … learned can minimize future occurrences. … July 17, 2019 Lessons learned from implementing a principled approach to resolution following

180. What a new doctor learned about medical mistakes from her Mom's death. | PSNet
     psnet.ahrq.gov/issue/what-new-doctor-learned-about-medical-mistakes-her-moms-death
     March 03, 2021 - Newspaper/Magazine Article What a new doctor learned about medical mistakes from … Citation Text: What a new doctor learned about medical mistakes from her Mom's death. Allen M. … This article reveals lessons a medical student learned about patient safety while dealing with errors … Copy URL Cite Citation Citation Text: What a new doctor learned