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Showing results for "lessons learned".

2021. Algorithmic Bias Playbook. | PSNet
      psnet.ahrq.gov/issue/algorithmic-bias-playbook
      May 13, 2020 - December 9, 2020 View More Related Resources Lessons from the Covid

2022. Educational opportunities with postevent debriefing. | PSNet
      psnet.ahrq.gov/issue/educational-opportunities-postevent-debriefing
      May 28, 2015 - February 6, 2014 Building a safer foundation: the Lessons Learnt patient safety training

2023. A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1. | PSNet
      psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident
      September 28, 2010 - suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons

2024. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60261/psn-pdf
      April 22, 2020 - 2019-covid-19 https://psnet.ahrq.gov/issue/patient-safety-recommendations-covid-19-epidemic-outbreak-lessons-italian-experience

2025. Learning from excellence in healthcare: a new approach to incident reporting. | PSNet
      psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
      August 31, 2022 - October 9, 2019 Quality improvement priorities for safer out-of-hours palliative care: lessons

2026. Don’t Bite Your Tongue. | PSNet
      psnet.ahrq.gov/web-mm/dont-bite-your-tongue
      September 18, 2024 - September 18, 2024 The safety journal: lessons learned with an error reporting tool to … Perspective Assessing the Safety of Electronic Health Records: What Have We Learned

2027. Situational (Un)Awareness | PSNet
      psnet.ahrq.gov/web-mm/situational-unawareness
      August 01, 2009 - On Wednesday morning rounds, the attending physician learned that the patient had not yet received any … The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons … learned from a multisite qualitative study.

2028. An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing and learning for patient safety? | PSNet
      psnet.ahrq.gov/issue/exploratory-study-knowledge-brokering-hospital-settings-facilitating-knowledge-sharing-and
      July 02, 2008 - 19, 2016 Culture and behaviour in the English National Health Service: overview of lessons

2029. Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. | PSNet
      psnet.ahrq.gov/issue/incident-learning-pursuit-high-reliability-implementing-comprehensive-low-threshold-reporting
      September 27, 2017 - November 6, 2015 Improving patient safety in clinical oncology: applying lessons from

2030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838926/psn-pdf
      October 26, 2022 - criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-patient-safety https://psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals

2031. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46072/psn-pdf
      November 08, 2017 - fifth-discipline-art-practice-learning-organization-revised-updated-edition https://psnet.ahrq.gov/issue/implementing-national-strategy-patient-safety-lessons-national-health-service-england

2032. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36837/psn-pdf
      December 03, 2018 - -1984 https://psnet.ahrq.gov/primer/culture-safety https://psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations-bristol-royal

2033. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33578/psn-pdf
      September 15, 2024 - primer/human-factors-engineering https://psnet.ahrq.gov/issue/shaping-systems-better-behavioral-choices-lessons-learned-fatal-medication-error

2034. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33570/psn-pdf
      June 15, 2024 - As applied to health care, we have learned that clinicians frequently use heuristics (shortcuts or " … analysis-surgical-errors-closed-malpractice-claims-4-liability-insurers https://psnet.ahrq.gov/issue/patient-safety-and-telephone-medicine-some-lessons-closed-claim-case-review

2035. The Report of the Short Life Working Group on Reducing Medication-related Harm. | PSNet
      psnet.ahrq.gov/issue/report-short-life-working-group-reducing-medication-related-harm
      September 09, 2015 - October 5, 2022 Culture Change in the NHS: Applying the Lessons of the Francis Inquiries

2036. AHRQ quality and safety initiatives. | PSNet
      psnet.ahrq.gov/issue/ahrq-quality-and-safety-initiatives
      May 20, 2009 - Related Resources From the Same Author(s) Reducing health care hazards: lessons

2037. Patient safety and interprofessional education: a report of key issues from two interprofessional workshops. | PSNet
      psnet.ahrq.gov/issue/patient-safety-and-interprofessional-education-report-key-issues-two-interprofessional
      August 20, 2018 - Lessons from a series of research on teamwork, leadership and team training. … November 20, 2013 Improving patient safety: lessons from rock climbing.

2038. Improving patient care by linking evidence-based medicine and evidence-based management. | PSNet
      psnet.ahrq.gov/issue/improving-patient-care-linking-evidence-based-medicine-and-evidence-based-management
      October 06, 2011 - Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning lessons … October 21, 2009 Reducing health care hazards: lessons from the Commercial Aviation Safety

2039. One hospital's initiatives to encourage safe opioid use. | PSNet
      psnet.ahrq.gov/issue/one-hospitals-initiatives-encourage-safe-opioid-use
      October 19, 2022 - April 17, 2019 Teaching patient safety in global health: lessons from the Duke Global … October 31, 2018 Addressing the opioid epidemic in the United States: lessons from the

2040. Continuous improvement as an ideal in health care. | PSNet
      psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
      August 04, 2021 - February 3, 2011 Reducing adverse drug events: lessons from a breakthrough series collaborative … June 7, 2018 Safety lessons from the NIH Clinical Center.