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Showing results for "lessons learned".

2821. The Role of Undergraduate Nursing Education in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
      November 27, 2023 - 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 … 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

2822. In Conversation With...Donald A. Norman, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
      November 01, 2006 - We have learned a lot about how automation has been introduced to other industries, to know that it always … By being the last in line to automate, we may be able to take advantage of what we've learned from errors … The Art of Innovation; Lessons in Creativity from IDEO, Americas Leading Design Firm.

2823. Health Care Data Science for Quality Improvement and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
      October 01, 2016 - in Acute Hospital Care Units April 26, 2023 Changing smart pump vendors: lessons … learned. … Perspective Assessing the Safety of Electronic Health Records: What Have We Learned

2824. In Conversation With… Susan E. Skochelak, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
      February 01, 2019 - We have learned that creating such a transparent and just culture does not automatically result from … conducive environment to not only teach the foundations of health systems science, but to reinforce these lessons

2825. Good Catch in the Operating Room | PSNet
      psnet.ahrq.gov/web-mm/good-catch-operating-room
      August 27, 2017 - Spine Surgery February 28, 2024 Understanding ultrarare adverse events - lessons … learned from a twelve-year review of intraoperative deaths at an academic medical center.

2826. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet
      psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
      December 14, 2022 - December 14, 2022 Lessons learned in implementing a chronic opioid therapy management

2827. 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

2828. 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.

2829. 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

2830. "Superficial" Report Leads to "Deep" Problem | PSNet
      psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
      July 01, 2012 - "Superficial" Report Leads to "Deep" Problem Citation Text: Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndN…

2831. Tacit Handover, Overt Mishap | PSNet
      psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
      August 01, 2006 - 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

2832. Production Pressures | PSNet
      psnet.ahrq.gov/web-mm/production-pressures
      November 16, 2022 - Usability of a human factors-based clinical decision support in the emergency department: lessons … learned for design and implementation.

2833. The Safety Challenges of Supervision and Night Coverage in Academic Residency | PSNet
      psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
      February 21, 2024 - In the discussion, he learned that the intern had never before rotated at this particular hospital and … ) Identifying and classifying diagnostic errors in acute care across hospitals: early lessons

2834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33663/psn-pdf
      September 15, 2008 - that others, particularly those in large, multisite systems, might benefit from the experiences and lessons … learned along our journey.

2835. Are We Getting Better at Measuring Patient Safety? | PSNet
      psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
      November 10, 2015 - January 27, 2019 Quality improvement lessons learned from National Implementation of

2836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836850/psn-pdf
      March 31, 2022 - Future lessons learned from this project will be valuable for reducing ADEs from PIMs. 

2837. Long-Term Care and the Response to COVID-19 | PSNet
      psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19
      October 28, 2020 - While management of the infection has improved as the pandemic has continued and facilities have learned … your initiative and its intersection with the COVID-19 response – how are you using the work and the lessons … I would encourage frontline staff in hard hit areas to use forums like that to share what they’ve learned … We are not New York, so some lessons didn’t apply.

2838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60376/psn-pdf
      July 30, 2020 - psychological-impact-and-coping-strategies-frontline-medical-staff-hunan-between-january-and https://psnet.ahrq.gov/issue/patient-safety-recommendations-covid-19-epidemic-outbreak-lessons-italian-experience

2839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33645/psn-pdf
      February 01, 2007 - Diagnosing diagnosis errors: Lessons from a multi-institutional collaborative project for the diagnostic

2840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33730/psn-pdf
      June 01, 2012 - The idea was to aggregate the existing reporting systems and learn lessons nationally.