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Total Results: 3,005 records

Showing results for "lessons learned".

2781. A Seasonal Care Transition Failure | PSNet
      psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
      June 01, 2016 - Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons … Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons

2782. In Conversation with… Michael Cohen, RPh, MS, ScD (hon) | PSNet
      psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
      April 01, 2006 - Can you share some of the lessons that you have learned through your work that are relevant to other

2783. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety | PSNet
      psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
      April 01, 2006 - Can you share some of the lessons that you have learned through your work that are relevant to other

2784. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
      February 26, 2025 - You just must establish trust with the partners and have the willingness to share what is learned. … that may be missed without effective reporting and analysis in combination with dissemination of the lessons … learned.

2785. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33768/psn-pdf
      June 01, 2014 - Robert Wachter, Editor, AHRQ WebM&M: What have you learned since you entered the world of medicine and … Antibiotics, what we've come to understand about cancer, and all that—we have correctly learned to worship … I learned that if you understand structural thinking—if you understand feedback loops and the cultural … Another aspect arose when I learned about the Institute of Medicine's Best Care at Lower Cost report

2786. 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

2787. In Conversation With… Gordon Schiff, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
      February 26, 2025 - RW : What have we learned in the last 5 or 10 years about trying to measure diagnostic errors? … We've been looking at malpractice cases for lessons. … One thing we've learned is that stories are very important.

2788. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865413/psn-pdf
      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.

2789. Patient Safety and Health Information Technology: Learning from Our Mistakes | PSNet
      psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
      July 01, 2012 - equals patient safety, and more health IT equals more patient safety .( 7 ) Paradoxically, we've learned … H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations. … DB : What I learned was that whenever a lot of money is made available by our government for anything … So there were a whole series of things that I learned in Washington that are applicable even in this

2790. In Conversation With… David Blumenthal, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
      July 01, 2012 - DB : What I learned was that whenever a lot of money is made available by our government for anything … So there were a whole series of things that I learned in Washington that are applicable even in this … equals patient safety, and more health IT equals more patient safety .( 7 ) Paradoxically, we've learned … H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations.

2791. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33635/psn-pdf
      July 01, 2006 - RW: What have you learned about physician pushback in terms of standardization, and what tips would … That's probably the most important lesson I've learned.

2792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49595/psn-pdf
      December 01, 2009 - "Superficial" Report Leads to "Deep" Problem December 1, 2009 Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem The Case A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…

2793. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33797/psn-pdf
      January 01, 2016 - Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health record.

2794. EHR Copy and Paste and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
      January 01, 2018 - Duly noted: lessons from a two-site intervention to assess and improve the quality of clinical documentation … Are there deeper lessons from what you've observed in how we use our electronic tools than simply that … Perspective Assessing the Safety of Electronic Health Records: What Have We Learned … Perspective Assessing the Safety of Electronic Health Records: What Have We Learned

2795. In Conversation With... James P. Bagian, MD, PE | PSNet
      psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
      February 26, 2025 - 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

2796. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33841/psn-pdf
      September 01, 2017 - We've learned that even really well-designed software can be made very challenging for clinicians when … One of the key lessons is to be more of a learning system all the way through. AG: Absolutely.

2797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49627/psn-pdf
      June 01, 2011 - Editorial Note: The physician (case submitter) further reflected on what he learned from this experience … These are the smaller lessons from this case.

2798. Preventable Transfer to the Hospital | PSNet
      psnet.ahrq.gov/web-mm/preventable-transfer-hospital
      March 31, 2022 - Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: lessons learned

2799. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - August 5, 2009 The safety journal: lessons learned with an error reporting tool to stimulate

2800. DRESSed for Failure | PSNet
      psnet.ahrq.gov/web-mm/dressed-failure
      September 01, 2011 - The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons … learned from a multisite qualitative study.