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Showing results for "lessons learned".

2701. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
      January 12, 2022 - also hosted Safe Table discussions, where members of the PSO share COVID-19-related safety issues and lessons … learned in a protected, safe environment. … an event analysis, we held Safe Table discussions and invited providers to come with what they had learned … KH: What have you learned about the impact of COVID-19 on patient safety? … We learned that PPE hinders communication.

2702. In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO | PSNet
      psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
      January 12, 2022 - also hosted Safe Table discussions, where members of the PSO share COVID-19-related safety issues and lessons … learned in a protected, safe environment. … an event analysis, we held Safe Table discussions and invited providers to come with what they had learned … KH: What have you learned about the impact of COVID-19 on patient safety? … We learned that PPE hinders communication.

2703. A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries | PSNet
      psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
      July 23, 2024 - technical assistance A means for peer-group sharing of best practices Use By Other Organizations   Lessons … Lessons Learned from Implementing a Place-Based, Racial Justice-Centered Approach to Health Equity.

2704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61083/psn-pdf
      October 28, 2020 - your initiative and its intersection with the COVID-19 response – how are you using the work and the lessons … I would encourage frontline staff in hard hit areas to use forums like that to share what they’ve learned … We are not New York, so some lessons didn’t apply.

2705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49699/psn-pdf
      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.

2706. Safety In Dentistry | PSNet
      psnet.ahrq.gov/perspective/safety-dentistry
      August 01, 2016 - efficiently detect dental charts that contain patient safety events.( 2,16,17 ) One important point we have learned … Lessons learned from dental patient safety case reports. J Am Dent Assoc. 2015;146:318-326.e2. … We think the principle of patient safety must be learned at the beginning of health education.

2707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867653/psn-pdf
      February 26, 2025 - Ochsner’s Chief Quality Officer learned about RCA2 during a conference and was so impacted that we soon … We learned from other organizations that those are not sustainable actions. … Sarah Mossburg: What are the main lessons you have learned from years of completing RCAs and RCA2 ?

2708. In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
      August 01, 2016 - We think the principle of patient safety must be learned at the beginning of health education. … efficiently detect dental charts that contain patient safety events.( 2,16,17 ) One important point we have learned … Lessons learned from dental patient safety case reports. J Am Dent Assoc. 2015;146:318-326.e2.

2709. Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes | PSNet
      psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
      July 23, 2024 - Structured communication techniques: Participants learned structured communication, teamwork and situational … Participants also received and learned to use forms to document communication. … Chair of the Department of Obstetrics and Gynecology and now Director of PROMPT for North America, learned … Lessons from a series of research on teamwork, leadership and team training.

2710. Low on the Totem Pole | PSNet
      psnet.ahrq.gov/web-mm/low-totem-pole
      October 01, 2003 - A generation ago, aviation learned the lesson from several horrible accidents that tragedy can often … Rather than risking a false alarm and its accompanying stigma, they have learned to say, “Oh, it’s probably … The complexity of team training: what we have learned from aviation and its applications to medicine.

2711. The Missing Suction Tip | PSNet
      psnet.ahrq.gov/web-mm/missing-suction-tip
      January 01, 2006 - This lesson has been learned from years of research on human performance in aviation and other industries … January 2, 2017 Counting matters: lessons from the root cause analysis of a retained

2712. Fumbled Handoff | PSNet
      psnet.ahrq.gov/web-mm/fumbled-handoff
      September 01, 2006 - April 30, 2014 Project BOOST implementation: lessons learned.

2713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865570/psn-pdf
      April 10, 2024 - Anesthesia adverse events voluntarily reported in the Veterans health administration and lessons learned

2714. The Wild West: Patient Safety in Office-Based Anesthesia | PSNet
      psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
      April 01, 2003 - January 12, 2011 Adverse event reporting: lessons learned from 4 years of Florida office

2715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865418/psn-pdf
      March 27, 2024 - .10 Finally, it is critically important for the organization to debrief about the event, determine lessons … learned, and develop a plan for carrying out action items.

2716. Medication Overdose | PSNet
      psnet.ahrq.gov/web-mm/medication-overdose
      September 01, 2011 - The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons … learned from a multisite qualitative study.

2717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837658/psn-pdf
      July 08, 2022 - Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: lessons learned

2718. Wrong-side Bedside Paravertebral Block: Preventing the Preventable | PSNet
      psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
      August 10, 2019 - Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149:774-779.

2719. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33876/psn-pdf
      August 01, 2018 - networks can communicate across their systems with relative ease, hopefully sharing best practices and lessons … learned from within the system itself.

2720. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33705/psn-pdf
      January 01, 2011 - We recommend that organizations use the lessons from malpractice claims to improve systems of care. … The American Society of Anesthesiology Closed Claims Project: what have we learned, how has it affected