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Showing results for "lessons learned".

1881. 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.

1882. 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.

1883. 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

1884. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43870/psn-pdf
      January 28, 2015 - https://psnet.ahrq.gov/issue/improving-healthcare-quality-through-organisational-peer-peer-assessment-lessons-nuclear

1885. ABCDEF Bundle Data Literacy Training, Performance Measurement Tracking, and Performance Feedback | PSNet
      psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
      September 23, 2024 - Operations Business Intelligence, Value Improvement Office (referred to throughout as the Innovation Team) learned … Lessons learned from a systematic, hospital-wide implementation of the ABCDEF bundle: a survey evaluation … Lessons Learned From a Systematic, Hospital-Wide Implementation of the ABCDEF Bundle: A Survey Evaluation

1886. 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 … Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident … Mind the gap between recommendation and implementation—principles and lessons in the aftermath of incident

1887. Three Australian whistleblowing sagas: lessons for internal and external regulation. | PSNet
      psnet.ahrq.gov/issue/three-australian-whistleblowing-sagas-lessons-internal-and-external-regulation
      August 17, 2005 - Study Three Australian whistleblowing sagas: lessons for internal and external regulation … Three Australian whistleblowing sagas: lessons for internal and external regulation. … Three Australian whistleblowing sagas: lessons for internal and external regulation.

1888. Lessons from the war on cancer: the need for basic research on safety. | PSNet
      psnet.ahrq.gov/issue/lessons-war-cancer-need-basic-research-safety
      July 14, 2010 - Commentary Lessons from the war on cancer: the need for basic research on safety. … Citation Text: Lessons from the war on cancer: the need for basic research on safety. Cook RI. … Linkedin Copy URL Cite Citation Citation Text: Lessons

1889. 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

1890. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48173/psn-pdf
      August 28, 2019 - suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons

1891. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
      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.

1892. Interpreting the Patient Safety Literature | PSNet
      psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
      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.

1893. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33753/psn-pdf
      August 22, 2013 - Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented

1894. 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?

1895. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837791/psn-pdf
      August 05, 2022 - maintaining adequate access to ambulatory care and reliable diagnostic services, have been informed by lessons … Next Steps in Ambulatory Care Safety Over the last three decades, many lessons have been learned and … These demonstration and implementation projects could further accelerate the application of lessons … learned to help safety leaders better understand and, ultimately, decrease adverse events in ambulatory

1896. Transformational improvement in quality care and health systems: the next decade. | PSNet
      psnet.ahrq.gov/issue/transformational-improvement-quality-care-and-health-systems-next-decade
      October 14, 2020 - Annual Perspective Equity in Patient Safety March 27, 2024 Lessons … Improving Diagnostic Safety and Quality April 26, 2023 The Lancet Commission on lessons

1897. 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

1898. 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

1899. 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?

1900. 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?