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Total Results: 3,237 records

Showing results for "lessons learned".

181. Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health
     August 02, 2015 - Citation Related Resources From the Same Author(s) 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.

182. The Good, The Bad, and The Ugly: Patient Experiences with CRPs. | PSNet
     psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps
     February 28, 2024 - September 7, 2022 Lessons Learned about Human Fallibility, System Design, and Justice … June 26, 2019 A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing

183. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50782/psn-pdf
     January 08, 2020 - what-can-patient-safety-teach-us-about-clinician-burnout This commentary discusses how we can apply lessons … learned in patient safety to address clinician burnout. … Lessons include (1) focusing on systems-level factors, (2) institutional and leadership commitment to

184. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43695/psn-pdf
     August 02, 2015 - claims-errors-and-compensation-payments-medical-malpractice-litigation https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters … https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters

185. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37910/psn-pdf
     February 28, 2011 - Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance … Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance … https://psnet.ahrq.gov/issue/public-reporting-antibiotic-timing-patients-pneumonia-lessons-flawed- performance-measure … The authors conclude with a number of lessons learned from this case example, including the tension … https://psnet.ahrq.gov/issue/public-reporting-antibiotic-timing-patients-pneumonia-lessons-flawed-performance-measure

186. PSNet Curated Library (pdf file)
     psnet.ahrq.gov/print/pdf/node/848754
     January 01, 2025 - Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. … https://psnet.ahrq.gov/issue/implementing-hospital-based-communication-and-resolution-programs-lessons-learned-new-york … Implementing hospital-based communication-and-resolution programs: lessons learned in New York City. … https://psnet.ahrq.gov/issue/implementing-hospital-based-communication-and-resolution-programs-lessons-learned-new-york … https://psnet.ahrq.gov/issue/implementing-hospital-based-communication-and-resolution-programs-lessons-learned-new-york

187. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837146/psn-pdf
     May 18, 2022 - https://psnet.ahrq.gov/issue/transition-new-electronic-health-record-and-pediatric-medication-safety-lessons-learned … https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned

188. A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. | PSNet
     psnet.ahrq.gov/issue/national-trauma-care-system-integrating-military-and-civilian-trauma-systems-achieve-zero
     September 12, 2018 - This report discusses the need to ensure that lessons learned in military trauma care are acted on … May 12, 2021 Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis.

189. A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and its meetings. | PSNet
     psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its
     March 04, 2015 - describes one hospital's experience implementing  Failure Mode and Effects Analysis and highlights lessons … learned. … April 28, 2021 Shaping systems for better behavioral choices: lessons learned from a

190. Analyzing and discussing human factors affecting surgical patient safety using innovative technology: creating a safer operating culture. | PSNet
     psnet.ahrq.gov/issue/analyzing-and-discussing-human-factors-affecting-surgical-patient-safety-using-innovative
     August 25, 2021 - Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of … View More Related Resources Understanding ultrarare adverse events - lessons … learned from a twelve-year review of intraoperative deaths at an academic medical center.

191. Standardizing patient safety event reporting between care delivered or purchased by the Veterans Health Administration (VHA). | PSNet
     psnet.ahrq.gov/issue/standardizing-patient-safety-event-reporting-between-care-delivered-or-purchased-veterans
     June 26, 2024 - Citation Related Resources From the Same Author(s) Quality improvement lessons … learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation … Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons … learned from the field. … November 16, 2022 Designing an abstraction instrument: lessons from efforts to validate

192. CPS Annual Reports. | PSNet
     psnet.ahrq.gov/issue/cps-annual-reports
     March 25, 2009 - The material discusses reasons for these events, shares lessons learned, and points to resources to aid … January 16, 2013 Adverse Health Care Events Reporting System: What Have We Learned?

193. CANDOR Webinar Series. | PSNet
     psnet.ahrq.gov/issue/candor-webinar-series
     June 01, 2023 - October 20, 2021 The evolution of the Anesthesia Patient Safety Movement in America: lessons … learned and considerations to promote further improvement in patient safety. … September 7, 2022 Lessons Learned about Human Fallibility, System Design, and Justice

194. Human factors engineering: its place and potential in OR safety. | PSNet
     psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety
     May 24, 2017 - September 28, 2022 Lessons learned implementing a complex and innovative patient safety … January 18, 2023 Lessons learned in implementing a chronic opioid therapy management … Lessons from aviation to improve patient safety.

195. Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons from other parts of the public sector? | PSNet
     psnet.ahrq.gov/issue/developing-critical-approach-patient-and-public-involvement-patient-safety-nhs-learning
     February 20, 2019 - Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons … Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons … Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons … June 25, 2014 Governing patient safety: lessons learned from a mixed methods evaluation … 29, 2014 Prospects for comparing European hospitals in terms of quality and safety: lessons

196. Recognizing Unsafe Care: What It Is and How to Report It. | PSNet
     psnet.ahrq.gov/issue/recognizing-unsafe-care-what-it-and-how-report-it
     April 22, 2020 - June 21, 2023 Lessons Learned about Human Fallibility, System Design, and Justice in … May 8, 2017 A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing

197. Patient, Medical, and Legal Perspectives of Unsafe Care. | PSNet
     psnet.ahrq.gov/issue/patient-medical-and-legal-perspectives-unsafe-care
     July 20, 2021 - June 1, 2021 The evolution of the Anesthesia Patient Safety Movement in America: lessons … learned and considerations to promote further improvement in patient safety. … September 7, 2022 Lessons Learned about Human Fallibility, System Design, and Justice

198. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43315/psn-pdf
     May 10, 2016 - this commentary relates how two organizations implemented this strategy along with challenges and lessons … learned. … psnet.ahrq.gov/issue/sustaining-quality-improvement-and-patient-safety-training-graduate-medical-education-lessons

199. The safe day call: reducing silos in health care through frontline risk assessment. | PSNet
     psnet.ahrq.gov/issue/safe-day-call-reducing-silos-health-care-through-frontline-risk-assessment
     May 25, 2016 - The authors review the results and lessons learned in the 4 years following the intervention. … October 1, 2014 Project BOOST implementation: lessons learned.

200. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43106/psn-pdf
     September 27, 2016 - The authors relate lessons learned from their experience. … sterile-cockpit-effective-approach-reducing-medication-errors https://psnet.ahrq.gov/issue/error-management-lessons-aviation