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Showing results for "lessons learned".

2761. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - The Commentary While there is something to be learned about the proper care of spinal catheters from … Handoff strategies in settings with high consequences for failure: lessons for health care operations

2762. Diagnostic Errors Case Studies | PSNet
      psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
      July 21, 2025 - PRIDE Learning Network, diagnostic error case studies were reviewed to identify common pitfalls and lessons … learned.

2763. Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner | PSNet
      psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
      February 26, 2025 - Anesthesia adverse events voluntarily reported in the Veterans health administration and lessons learned

2764. Missed CANDOR Implementation Opportunities. | PSNet
      psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
      November 11, 2020 - was no plan or commitment made to the widow to follow up with her and further explain what was later learned … The lessons learned and improvements made in response to the adverse event should also be explained,

2765. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840174/psn-pdf
      August 28, 2024 - was no plan or commitment made to the widow to follow up with her and further explain what was later learned … The lessons learned and improvements made in response to the adverse event should also be explained,

2766. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33638/psn-pdf
      August 01, 2006 - I learned an important lesson: enlightened, risk-taking leadership is the only way to achieve significant

2767. Dangerous Shift | PSNet
      psnet.ahrq.gov/web-mm/dangerous-shift
      July 24, 2013 - 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

2768. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33796/psn-pdf
      January 01, 2016 - 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

2769. Application of Safety-II Principles | PSNet
      psnet.ahrq.gov/perspective/application-safety-ii-principles
      August 28, 2024 - At that conference, we learned from other industries, such as aviation and nuclear power, sharing practical … Sarah Mossburg: Are there any lessons learned or advice that you would provide to other organizations

2770. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet
      psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
      August 28, 2024 - At that conference, we learned from other industries, such as aviation and nuclear power, sharing practical … Sarah Mossburg: Are there any lessons learned or advice that you would provide to other organizations

2771. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841566/psn-pdf
      December 14, 2022 - However, we all know that healthcare requires data which is timely and interoperable; we certainly learned … establishing the systems of safety and those key tools of high-reliability organizations that we have learned … There are many lessons here, including communication strategies, culture, leadership, teamwork training

2772. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846563/psn-pdf
      March 21, 2023 - Lessons learned from adverse events could help improve future patient safety.

2773. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
      August 01, 2015 - information to enable clear identification of patients (and promote patient safety) 15 15 Key Lessons

2774. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - 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.

2775. In Conversation With… Alison Holmes, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
      March 01, 2014 - What are a few lessons that people in the infection world have learned that might be relevant to patient … Why do you think that difference arose, and are lessons about how the infection world collects evidence … is worth reflecting on the growth and development of such programs; this history may hold important lessons

2776. How Does Infection Prevention Fit Into a Safety Program? | PSNet
      psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
      March 01, 2014 - is worth reflecting on the growth and development of such programs; this history may hold important lessons … What are a few lessons that people in the infection world have learned that might be relevant to patient … Why do you think that difference arose, and are lessons about how the infection world collects evidence

2777. In Conversation With… Urmimala Sarkar, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
      August 22, 2014 - RW : Are there any other differences that make it hazardous to extrapolate things we've learned from … being partly we've never had the organizational model, partly finances, partly because physicians never learned … 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? … Safety in the Outpatient Setting While much of our progress will come from adapting the things we have learned

2778. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33700/psn-pdf
      October 01, 2010 - PP: One of the key lessons that I've learned is that there are different types of problems in safety

2779. Impact of System Failures on Healthcare Workers | PSNet
      psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
      August 30, 2023 - Lessons learned from adverse events could help improve future patient safety.

2780. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up | PSNet
      psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
      December 01, 2005 - But, in the patient safety arena, I found significant challenges, ones that hold lessons for the American … Understanding the factors influencing implementation of a new national patient safety policy in England: lessons