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Showing results for "lessons learned".

  1. 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

  2. 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

  3. 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.

  4. 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.

  5. 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…

  6. 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.

  7. 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

  8. 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.

  9. 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.

  10. 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.

  11. 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

  12. 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.

  13. 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.

  14. In Conversation With… Harlan Krumholz, MD, SM | PSNet

    psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
    April 01, 2018 - themes of the last 20 years of improvement work has been unanticipated consequences, and we've now learned … RW : As a learning health system, what do you think the lessons are from readmission penalties? … What have we learned from that measure that is generalizable to our efforts to change the payment and … willing to work together and could collectively achieve a gain, then they could disseminate what they learned

  15. Adverse Events in Dentistry | PSNet

    psnet.ahrq.gov/perspective/adverse-events-dentistry
    December 22, 2020 - Lessons learned from dental patient safety care reports. … One of the things we learned from a culture survey we did was that the two areas that we were particularly … The difference between medical and dental school that I learned when I came into the school is that the

  16. In Conversation With... Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
    December 22, 2020 - One of the things we learned from a culture survey we did was that the two areas that we were particularly … The difference between medical and dental school that I learned when I came into the school is that the … Lessons learned from dental patient safety care reports.

  17. 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.

  18. 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

  19. 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

  20. 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
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