Results

Total Results: 3,006 records

Showing results for "lessons learned".

1901. Understanding and learning from organisational failure. | PSNet
      psnet.ahrq.gov/issue/understanding-and-learning-organisational-failure
      April 19, 2011 - Citation Related Resources From the Same Author(s) A very public failure: lessons

1902. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33787/psn-pdf
      January 01, 2018 - RW: One of the early things you did was team up with industry to look for lessons from outside of health … As you have observed this world over the last 20 years or so, what lessons do you think are really powerful … MB: I am increasingly out in the field and looking to these other industries for new lessons in safety … What have we learned from trying to do that? MB: I think we've put a human face on a problem. … So what have you learned as the leader that you didn't know as second in command?

1903. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33865/psn-pdf
      September 01, 2018 - RW: In terms of what you eventually ended up applying in patient safety, what were the general lessons … RL: The general lessons were very much around needing to understand safety in a complex system and understand … We learned that patients found it difficult to understand what you meant by safety incidents when we … What have you learned about that and whether it's acceptable to patients and whether it works? … RL: Some of this is in the published literature, and some of it is what we've learned from doing work

1904. 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

1905. 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?

1906. A multi-tiered approach to safety education. | PSNet
      psnet.ahrq.gov/issue/multi-tiered-approach-safety-education
      January 31, 2018 - July 10, 2019 The Lancet Commission on lessons for the future from the COVID-19 pandemic … Sustaining quality improvement and patient safety training in graduate medical education: lessons

1907. In Conversation with...Sir Liam Donaldson, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
      May 01, 2007 - That's where we can go back to the lessons of the airline industry. … What have you learned about the commonalities and differences as you try to share patient safety learnings … It described the NHS as having an old-fashioned approach to learning lessons when things go wrong and … Mechanisms for ensuring that, where lessons are identified, the necessary changes are put into practice … 2001, charged with establishing a national reporting and learning system for adverse events, taking lessons

1908. Patient Safety in the Ambulatory Care Setting | PSNet
      psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
      April 27, 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

1909. Health care safety during the pandemic and beyond--building a system that ensures resilience. | PSNet
      psnet.ahrq.gov/issue/health-care-safety-during-pandemic-and-beyond-building-system-ensures-resilience
      July 20, 2022 - April 21, 2021 View More Related Resources Lessons from the Covid … May 10, 2023 The Lancet Commission on lessons for the future from the COVID-19 pandemic

1910. An organizational learning framework for patient safety. | PSNet
      psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
      November 28, 2018 - patient safety training January 13, 2021 Teaching patient safety in global health: lessons

1911. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44089/psn-pdf
      April 22, 2015 - root-cause-analysis https://psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident

1912. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42525/psn-pdf
      November 20, 2013 - promise-learn-commitment-act-improving-safety-patients-england https://psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care

1913. In response to “Getting to the Root of the Matter” (June 2005) | PSNet
      psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
      June 01, 2005 - July 14, 2010 Hospitalists as Emerging Leaders in Patient Safety: lessons learned and

1914. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
      February 01, 2014 - Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. … Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

1915. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46446/psn-pdf
      September 27, 2017 - journey-toward-high-reliability-comprehensive-safety-program-improve-quality-care-and-safety https://psnet.ahrq.gov/primer/high-reliability https://psnet.ahrq.gov/issue/error-management-lessons-aviation … https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations

1916. Diagnostic error in a national incident reporting system in the UK. | PSNet
      psnet.ahrq.gov/issue/diagnostic-error-national-incident-reporting-system-uk
      February 15, 2013 - February 4, 2015 Building a safer foundation: the Lessons Learnt patient safety training … July 6, 2012 Case-based learning for patient safety: the Lessons Learnt program for UK

1917. 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

1918. In Conversation With… Andrew Gettinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
      September 01, 2017 - We've learned that even really well-designed software can be made very challenging for clinicians when … One of the key lessons is to be more of a learning system all the way through. AG : Absolutely. … Assessing the Safety of Electronic Health Records: What Have We Learned? … Lessons learned from implementing service-oriented clinical decision support at four sites: a qualitative … Computer crash--lessons from a system failure. N Engl J Med. 2003;348:881-882.

1919. 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?

1920. 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?