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Showing results for "lessons learned".

2761. An Obstructed View | PSNet
      psnet.ahrq.gov/web-mm/obstructed-view
      August 07, 2019 - January 10, 2024 Patients' perspectives on quality and patient safety failures: lessons … learned from an inquiry into transvaginal mesh in Australia.

2762. Cybersecurity and How to Maintain Patient Safety | PSNet
      psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
      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. … there is an operational issue or crisis, we create an after-action report to identify best practices, lessons … learned, and the plan for the future.

2763. In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity | PSNet
      psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
      March 27, 2024 - there is an operational issue or crisis, we create an after-action report to identify best practices, lessons … learned, and the plan for the future. … 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.

2764. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49487/psn-pdf
      August 21, 2005 - Our experience was telling, and we share it in hopes that the lessons will be relevant to others who

2765. Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
      February 26, 2025 - that may be missed without effective reporting and analysis in combination with dissemination of the lessons … learned. … You just must establish trust with the partners and have the willingness to share what is learned.

2766. 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

2767. 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

2768. 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

2769. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33828/psn-pdf
      March 01, 2017 - 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

2770. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33820/psn-pdf
      December 01, 2016 - We spoke with him about the RCA2 report and what we have learned about root cause analysis in health … RW: What do you think the lessons of the last 15 or so years have been as we've tried to apply this

2771. 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

2772. 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

2773. 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

2774. 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

2775. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33878/psn-pdf
      April 01, 2019 - In the US, I first learned about them with the Lexington VA study and the early Michigan studies probably … www.ncbi.nlm.nih.gov/pubmed/16615397 https://psnet.ahrq.gov/issue/communication-and-resolution-programs-challenges-and-lessons-learned-six-early-adopters

2776. 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.

2777. 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

2778. 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

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