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Showing results for "lessons learned".

2801. Liposuction Gone Awry | PSNet
      psnet.ahrq.gov/web-mm/liposuction-gone-awry
      July 01, 2003 - Routine Goes Awry June 1, 2011 Adverse event reporting: lessons … learned from 4 years of Florida office data.

2802. Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration | PSNet
      psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
      October 30, 2024 - The lessons learned from the pilot were then applied to a staggered deployment of the innovation to an

2803. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
      August 01, 2009 - many academic and consumer articles, which focus on optimizing organizational effectiveness through lessons … While rivals were in the mindset of planning, command, and control, Toyota had learned that no amount … several months, they started tackling this problem, these constant breakdowns in care, in the ways we learned … These people often find that there are so many disanalogies that the lessons aren't transferable.

2804. Workarounds and Resiliency on the Front Lines of Health Care | PSNet
      psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
      August 01, 2009 - many academic and consumer articles, which focus on optimizing organizational effectiveness through lessons … While rivals were in the mindset of planning, command, and control, Toyota had learned that no amount … several months, they started tackling this problem, these constant breakdowns in care, in the ways we learned … These people often find that there are so many disanalogies that the lessons aren't transferable.

2805. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33833/psn-pdf
      May 01, 2017 - I eventually learned that I'd probably harmed quite a number of patients with my well-intentioned prescribing … RW: What do you think the lessons are from this sad story for the health care system and for the field

2806. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33861/psn-pdf
      July 01, 2018 - 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.

2807. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. | PSNet
      psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
      August 25, 2021 - Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Lessons … learned in implementing a chronic opioid therapy management system.

2808. Making Healthcare Safer III Report | PSNet
      psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
      March 30, 2020 - adverse drug events, and others. [5] This edition of the report also includes contextual factors and lessons … learned that support successful implementation for each PSP. … SH: What is the area of the report that you personally learned the most from, either from reviewing or

2809. In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
      March 30, 2020 - SH: What is the area of the report that you personally learned the most from, either from reviewing or … adverse drug events, and others. [5] This edition of the report also includes contextual factors and lessons … learned that support successful implementation for each PSP.

2810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33789/psn-pdf
      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

2811. Falling Through the Crack (in the Bedrails) | PSNet
      psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
      February 19, 2020 - We learned from existing research that anticipated physiological falls can be prevented by following … July 29, 2020 Lessons learned implementing a complex and innovative patient safety learning

2812. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
      November 01, 2011 - Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.

2813. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73302/psn-pdf
      May 26, 2021 - I learned root-cause analysis when I was the Director of Clinical Services at MedStar (Mobile Healthcare

2814. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848107/psn-pdf
      April 26, 2023 - //psnet.ahrq.gov/issue/usability-human-factors-based-clinical-decision-support-emergency-department-lessons-learned

2815. Technology as a Tool for Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
      April 26, 2023 - The authors also presented evidence that it was cost-effective and detailed implementation lessons learned

2816. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33831/psn-pdf
      April 01, 2017 - RW: You said one of the early lessons was that you couldn't easily translate these observations from … And it goes back to the aphorism that I learned a long time ago from a very wise CIO who said, "Computers

2817. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49872/psn-pdf
      August 08, 2019 - Diagnosising diagnosis errors: lessons from a multi-institutional collaborative project.

2818. In Conversation With… Mark Graban, MS, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
      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.

2819. In Conversation With… Mary Dixon-Woods, DPhil | PSNet
      psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
      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 … s desire for more data was balanced with the intent to act on what they had already learned.

2820. In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
      November 27, 2023 - We learned through our conversations with clinical practices that we need a common language and similar … education is focused on being able to demonstrate what the learner can do with what they know or have learned … Safety concepts can be integrated into lessons to instill patient safety as a core competency in students … Clinical Rotations One of the most difficult parts of a nurse’s education is translating the theory learned