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Showing results for "lessons learned".

2241. What 'just culture' doesn't understand about just punishment. | PSNet
      psnet.ahrq.gov/issue/what-just-culture-doesnt-understand-about-just-punishment
      December 30, 2014 - 2023 Integrating principles of safety culture and just culture into nursing homes: lessons

2242. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. | PSNet
      psnet.ahrq.gov/issue/mortality-and-morbidity-rounds-mmr-pathology-relative-contribution-cognitive-bias-vs-systems
      May 18, 2022 - suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons

2243. The future of graduate medical education: a systems-based approach to ensure patient safety. | PSNet
      psnet.ahrq.gov/issue/future-graduate-medical-education-systems-based-approach-ensure-patient-safety
      October 18, 2017 - View More Related Resources Teaching patient safety in global health: lessons

2244. Data consistency in a voluntary medical incident reporting system. | PSNet
      psnet.ahrq.gov/issue/data-consistency-voluntary-medical-incident-reporting-system
      August 21, 2024 - April 8, 2018 Lessons learnt from incidents reported by postgraduate trainees in Dutch

2245. Preventing a parallel pandemic - a national strategy to protect clinicians' well-being. | PSNet
      psnet.ahrq.gov/issue/preventing-parallel-pandemic-national-strategy-protect-clinicians-well-being
      January 23, 2019 - 4, 2011 View More Related Resources The Lancet Commission on lessons

2246. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly what it was. | PSNet
      psnet.ahrq.gov/issue/really-stupid-mistake-it-does-feel-cop-out-blame-my-error-human-frailty-im-afraid-thats
      August 16, 2023 - suggests acknowledging and celebrating excellence (ACE) as a more positive way of teaching the same lessons

2247. Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems. | PSNet
      psnet.ahrq.gov/issue/hospital-ward-incidents-through-eyes-nurses-thick-description-appeal-and-deadlock-incident
      November 15, 2023 - 2015 Learning from morbidity and mortality conferences: focus and sustainability of lessons

2248. Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity | PSNet
      psnet.ahrq.gov/issue/medication-errors-emergency-departments-systematic-review-and-meta-analysis-prevalence-and
      April 02, 2014 - November 16, 2022 The Lancet Commission on lessons for the future from the COVID-19 pandemic

2249. Diagnostic Delay in the Emergency Department | PSNet
      psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
      September 18, 2024 - Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records. … Perspective Assessing the Safety of Electronic Health Records: What Have We Learned … August 30, 2023 The safety journal: lessons learned with an error reporting tool

2250. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846564/psn-pdf
      March 29, 2023 - The authors also presented evidence that it was cost-effective and detailed implementation lessons learned … //psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned

2251. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33710/psn-pdf
      May 01, 2011 - I think understanding what happened and what could have been done, or the lessons that might be learned

2252. Beyond the Hospital: the New Frontier of Patient Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
      August 01, 2014 - RW : Are there any other differences that make it hazardous to extrapolate things we've learned from … RW : You mentioned that some lessons from other industries that seem to be at least somewhat useful in … Are there lessons from other industries that do translate very well to the ambulatory side? … Perspective African Partnerships for Patient Safety: Lessons … Learned December 1, 2014 Perspective Overuse

2253. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
      January 01, 2016 - Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health record. … MG : We didn't know either, but after a few calls to the Institute of Medicine we learned. … Also I'm a huge fan of the AHRQ WebM&M conferences, and there are many, many valuable lessons in there … What I've learned is that IOM reports tend to stay at a very high level, and it's up to the stakeholders … August 7, 2024 The safety journal: lessons learned with an error reporting tool to stimulate

2254. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
      November 01, 2008 - decision-making (e.g., transfer patient now versus incur more shift changes & sign-outs) Assumptions & Lessons … Available at: http://www.ncbi.nlm.nih.gov/pubmed/18245211 Assumptions & Lessons (from Cognitive … contingency plans, and allow for flexibility to deviate in exceptional circumstances Assumptions & Lessons … page=637&calcTitle=1&title_id=9545&edition_id=10284 Assumptions & Lessons (3) (from Cognitive Engineering

2255. Polypharmacy | PSNet
      psnet.ahrq.gov/web-mm/polypharmacy
      March 01, 2007 - A number of lessons can be learned from this medication error, including those associated with optimal

2256. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33790/psn-pdf
      August 01, 2015 - implementations, we believe that health care systems and vendors would be well served by a library of lessons … learned and use cases that they can draw upon to design and install their systems.

2257. Second Victims: Support for Clinicians Involved in Errors and Adverse Events | PSNet
      psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
      December 15, 2024 - February 18, 2015 Clinician support: five years of lessons learned.

2258. Home | PSNet
      psnet.ahrq.gov/
      March 25, 2025 - ) Organizational learning is an environmental state that ensures lessons

2259. Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data. | PSNet
      psnet.ahrq.gov/issue/can-patient-safety-incident-reports-be-used-compare-hospital-safety-results-quantitative
      October 31, 2014 - January 13, 2010 Crisis management for surgical teams and their leaders, lessons from

2260. Patient and Family Roles in Safety | PSNet
      psnet.ahrq.gov/perspective/patient-and-family-roles-safety
      June 14, 2023 - I quickly learned that families were the experts. … There were some positive lessons learned about family presence during the COVID-19 pandemic. … We learned that we could conduct rounds in the hospital with families present via technology. … I think we learned some ways to make technology work for more people. … We’ve Been Here Before: Learning from the Lessons of the Past .