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Showing results for "lessons learned".

2721. Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes | PSNet
      psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
      February 26, 2025 - Caring beyond health care: lessons learned from a community-based partnership to reduce hospital readmission

2722. Workaround Error | PSNet
      psnet.ahrq.gov/web-mm/workaround-error
      October 30, 2024 - May 8, 2017 Developing a quality and safety curriculum for fellows: lessons learned from

2723. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. | PSNet
      psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review
      July 20, 2022 - Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons

2724. The relationship between patients' perception of care and measures of hospital quality and safety. | PSNet
      psnet.ahrq.gov/issue/relationship-between-patients-perception-care-and-measures-hospital-quality-and-safety
      February 13, 2019 - October 27, 2010 Tracking rates of patient safety indicators over time: lessons from

2725. Association of changing hospital readmission rates with mortality rates after hospital discharge. | PSNet
      psnet.ahrq.gov/issue/association-changing-hospital-readmission-rates-mortality-rates-after-hospital-discharge
      August 20, 2018 - Understanding the factors influencing implementation of a new national patient safety policy in England: lessons

2726. Challenges and remediation for Patient Safety Indicators in the transition to ICD-10-CM. | PSNet
      psnet.ahrq.gov/issue/challenges-and-remediation-patient-safety-indicators-transition-icd-10-cm
      September 23, 2020 - April 22, 2017 Designing an abstraction instrument: lessons from efforts to validate

2727. One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. | PSNet
      psnet.ahrq.gov/issue/one-size-fits-all-mixed-methods-evaluation-impact-100-single-room-accommodation-staff-and
      July 01, 2016 - 21, 2017 Prospects for comparing European hospitals in terms of quality and safety: lessons

2728. The association between complications, incidents, and patient experience: retrospective linkage of routine patient experience surveys and safety data. | PSNet
      psnet.ahrq.gov/issue/association-between-complications-incidents-and-patient-experience-retrospective-linkage
      February 20, 2019 - 2019 Learning from morbidity and mortality conferences: focus and sustainability of lessons

2729. Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications. | PSNet
      psnet.ahrq.gov/issue/intended-and-unintended-effects-large-scale-adverse-event-disclosure-controlled-after
      August 18, 2021 - 2015 Disclosing large scale adverse events in the US Veterans Health Administration: lessons

2730. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33776/psn-pdf
      January 01, 2015 - I love reading Don Berwick, Lucian Leape, and others who directly worked with or learned from Dr. … You see those types of lessons visiting a Toyota plant.

2731. The PeaceHealth Governance Journey in Support of Quality and Safety | PSNet
      psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
      August 01, 2007 - remainder of this article will provide a brief overview of the issues we have encountered and the key lessons … we have learned. … I learned that, rather than just fixing things for our practice or the guy down the hall, with the right … And what I learned was how difficult it is to make big changes in such systems. … of Dana Farber, went to talk to a particular hospital (which I won't name) about what Dana Farber learned

2732. Patient Safety: A Perspective from Office Practice | PSNet
      psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
      May 01, 2009 - It could be argued that physicians' learned helplessness training begins early in residency, where we … What have you learned and how would you change the educational process so that people have the skills … When I went to business school, I don't think I would have learned anything about health care if I had … I know when I went through medical school, I learned nothing about business. … May 22, 2024 Designing an abstraction instrument: lessons from efforts to validate the

2733. The Role of Bar Coding and Smart Pumps in Safety | PSNet
      psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
      September 01, 2008 - EP: At the Brigham and Women's Hospital, we have learned that, for a barcode system to be successful … Other things that we have learned at our hospital are that in order for barcode medication administration … course the VA has improved this technology, and we at the Brigham and Women's Hospital actually have learned … October 25, 2010 Intravenous medication safety and smart infusion systems: lessons learned

2734. In Conversation with...James L. Reinertsen, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
      August 01, 2007 - I learned that, rather than just fixing things for our practice or the guy down the hall, with the right … And what I learned was how difficult it is to make big changes in such systems. … of Dana Farber, went to talk to a particular hospital (which I won't name) about what Dana Farber learned … remainder of this article will provide a brief overview of the issues we have encountered and the key lessons … we have learned.

2735. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837324/psn-pdf
      July 08, 2022 - delivery for low-risk births Adoption Considerations Use by Others (Use By Other Organizations)   Lessons … Lessons Learned from Implementing a Place-Based, Racial Justice-Centered Approach to Health Equity.

2736. Simulation Training | PSNet
      psnet.ahrq.gov/primer/simulation-training
      September 15, 2024 - Primers Maternal Safety January 31, 2024 Quality improvement lessons … learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation

2737. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49573/psn-pdf
      January 01, 2009 - Basic assumptions and lessons distilled from the cognitive systems engineering literature (11-14) are … Overall, they highlight a number of important lessons that can be applied to health care settings. … Assumptions and Lessons from the Literature Assumptions Lessons Human behavior in professional settings

2738. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety | PSNet
      psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
      March 01, 2017 - s desire for more data was balanced with the intent to act on what they had already learned. … RW : During my training years, I learned precisely nothing about culture. … MDW : I would probably challenge you and say you learned an awful lot about culture as a medical student … So articulating that, codifying it, and saying, "Here are the lessons you can learn from the pain we … Resources From the Same Author(s) Perspective What We've Learned

2739. The ECG Is Not Normal | PSNet
      psnet.ahrq.gov/web-mm/ecg-not-normal
      November 10, 2015 - Editorial Note: The physician (case submitter) further reflected on what he learned from this experience … These are the smaller lessons from this case.

2740. In Conversation With… Robert M. Wachter, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
      August 01, 2015 - RW : I learned something from each interview, and it made it an incredibly rich experience. … I do think there are huge lessons to be drawn from those examples. … Finishing perhaps on a more personal note, how has the experience of writing the book and what you learned … 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.