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Showing results for "lessons learned".

1921. 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?

1922. 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.

1923. 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

1924. 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

1925. College of American Pathologists Special Topic Symposium on Error in Pathology and Laboratory Medicine—Practical Lessons for the Pathologist. | PSNet
      psnet.ahrq.gov/issue/college-american-pathologists-special-topic-symposium-error-pathology-and-laboratory-medicine
      May 31, 2006 - American Pathologists Special Topic Symposium on Error in Pathology and Laboratory Medicine—Practical Lessons … American Pathologists Special Topic Symposium on Error in Pathology and Laboratory Medicine—Practical Lessons … American Pathologists Special Topic Symposium on Error in Pathology and Laboratory Medicine—Practical Lessons

1926. Organizational learning in the morbidity and mortality conference. | PSNet
      psnet.ahrq.gov/issue/organizational-learning-morbidity-and-mortality-conference
      June 09, 2015 - Sustaining quality improvement and patient safety training in graduate medical education: lessons

1927. 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.

1928. Patient safety: threats and solutions. | PSNet
      psnet.ahrq.gov/issue/patient-safety-threats-and-solutions
      January 19, 2011 - 11, 2016 Culture and behaviour in the English National Health Service: overview of lessons … February 5, 2014 Building a safer foundation: the Lessons Learnt patient safety training

1929. Beyond "see one, do one, teach one": toward a different training paradigm. | PSNet
      psnet.ahrq.gov/issue/beyond-see-one-do-one-teach-one-toward-different-training-paradigm
      March 01, 2011 - July 19, 2023 Reducing health care hazards: lessons from the Commercial Aviation Safety … February 24, 2021 Teaching patient safety in global health: lessons from the Duke Global

1930. Implementing root cause analysis in an area health service: views of the participants. | PSNet
      psnet.ahrq.gov/issue/implementing-root-cause-analysis-area-health-service-views-participants
      December 03, 2014 - February 15, 2017 Addressing the opioid epidemic in the United States: lessons from the … , 2016 A method for prioritizing interventions following root cause analysis (RCA): lessons

1931. Disclosing medical errors to patients: a challenge for health care professionals and institutions. | PSNet
      psnet.ahrq.gov/issue/disclosing-medical-errors-patients-challenge-health-care-professionals-and-institutions
      April 19, 2017 - Sustaining quality improvement and patient safety training in graduate medical education: lessons … Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons

1932. Hospital-acquired SARS-CoV-2 infection: lessons for public health. | PSNet
      psnet.ahrq.gov/issue/hospital-acquired-sars-cov-2-infection-lessons-public-health
      November 25, 2020 - Commentary Hospital-acquired SARS-CoV-2 infection: lessons for public health. … Hospital-acquired SARS-CoV-2 infection: lessons for public health. … Hospital-acquired SARS-CoV-2 infection: lessons for public health. … October 12, 2022 The Lancet Commission on lessons for the future from the COVID-19 pandemic

1933. 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

1934. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841305/psn-pdf
      January 27, 2023 - Safety-I and Safety-II offer complementary perspectives about what work to examine and what lessons … may be learned. … Debriefing skills learned in simulation are very applicable to real patient care circumstances. … collaborate with leadership, healthcare workers, patients, and families, to apply skills and tactics learned

1935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45298/psn-pdf
      April 22, 2017 - effectiveness-and-efficiency-root-cause-analysis-medicine https://psnet.ahrq.gov/issue/mind-gap-between-recommendation-and-implementation-principles-and-lessons-aftermath-incident

1936. The science of safety improvement: learning while doing. | PSNet
      psnet.ahrq.gov/issue/science-safety-improvement-learning-while-doing
      August 04, 2021 - August 4, 2021 Reducing health care hazards: lessons from the Commercial Aviation Safety

1937. Applying lessons from social psychology to transform the culture of error disclosure. | PSNet
      psnet.ahrq.gov/issue/applying-lessons-social-psychology-transform-culture-error-disclosure
      March 20, 2024 - Commentary Applying lessons from social psychology to transform the culture of error … Applying lessons from social psychology to transform the culture of error disclosure. … Applying lessons from social psychology to transform the culture of error disclosure.

1938. Counting matters: lessons from the root cause analysis of a retained surgical item. | PSNet
      psnet.ahrq.gov/issue/counting-matters-lessons-root-cause-analysis-retained-surgical-item
      January 02, 2017 - Commentary Counting matters: lessons from the root cause analysis of a retained surgical … Counting matters: lessons from the root cause analysis of a retained surgical item. … Counting matters: lessons from the root cause analysis of a retained surgical item.

1939. Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons from New York City. | PSNet
      psnet.ahrq.gov/issue/restructuring-general-surgery-residency-program-epicenter-coronavirus-disease-2019-pandemic
      September 02, 2020 - Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons … Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons … Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons … October 28, 2020 "At home, with care": lessons from New York City home-based primary

1940. Reducing adverse drug events: lessons from a breakthrough series collaborative. | PSNet
      psnet.ahrq.gov/issue/reducing-adverse-drug-events-lessons-breakthrough-series-collaborative
      August 04, 2021 - Study Classic Reducing adverse drug events: lessons from … Reducing adverse drug events: lessons from a breakthrough series collaborative. … Reducing adverse drug events: lessons from a breakthrough series collaborative.