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Showing results for "lessons learned".

2821. 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.

2822. 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

2823. 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

2824. 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.

2825. 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

2826. 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.

2827. 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

2828. 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

2829. 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.

2830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49872/psn-pdf
      August 08, 2019 - Diagnosising diagnosis errors: lessons from a multi-institutional collaborative project.

2831. 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

2832. 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.

2833. 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

2834. 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

2835. 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

2836. 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.

2837. "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…

2838. 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. 

2839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33698/psn-pdf
      August 01, 2010 - RS: That's where the toolkit using lessons borrowed from Toyota is so widely applicable.

2840. What Makes a Good Checklist | PSNet
      psnet.ahrq.gov/perspective/what-makes-good-checklist
      October 01, 2010 - WHO surgical checklist embraced human factors principles, which helped user perception, they later learned … PP: One of the key lessons that I've learned is that there are different types of problems in safety