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Showing results for "lessons learned".

2841. In Conversation with...Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
      October 01, 2010 - PP: One of the key lessons that I've learned is that there are different types of problems in safety … WHO surgical checklist embraced human factors principles, which helped user perception, they later learned

2842. Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet
      psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
      November 01, 2006 - The Art of Innovation; Lessons in Creativity from IDEO, Americas Leading Design Firm. … 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

2843. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
      May 01, 2017 - Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.

2844. 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

2845. 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

2846. 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.

2847. In Conversation With… Mark Chassin, MD, MPP, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
      April 26, 2023 - 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

2848. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867428/psn-pdf
      December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…

2849. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49690/psn-pdf
      September 01, 2013 - Lessons learned in the abuse of pain relief medication: a focus on healthcare costs.

2850. Patient Safety During Hospital Discharge | PSNet
      psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
      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

2851. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
      February 26, 2025 - Ochsner’s Chief Quality Officer learned about RCA 2 during a conference and was so impacted that we … We learned from other organizations that those are not sustainable actions. … Sarah Mossburg: What are the main lessons you have learned from years of completing RCAs and RCA 2 ?

2852. The Evolution of Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/evolution-root-cause-analysis
      February 26, 2025 - Ochsner’s Chief Quality Officer learned about RCA 2 during a conference and was so impacted that we … We learned from other organizations that those are not sustainable actions. … Sarah Mossburg: What are the main lessons you have learned from years of completing RCAs and RCA 2 ?

2853. Innovations in Promoting Hand Hygiene Compliance | PSNet
      psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
      May 01, 2014 - RW : What have we learned about the use of bigger sticks that might be either public reporting (beyond … RW : What lessons from hand hygiene are relevant to trying to increase compliance with other safety practices … What we learned with hand hygiene was that system change was a definite prerequisite to the success of … What we learned from our experience is now spreading all over the world.

2854. In Conversation With… Didier Pittet, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
      May 01, 2014 - RW : What have we learned about the use of bigger sticks that might be either public reporting (beyond … RW : What lessons from hand hygiene are relevant to trying to increase compliance with other safety practices … What we learned with hand hygiene was that system change was a definite prerequisite to the success of … What we learned from our experience is now spreading all over the world.

2855. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions | PSNet
      psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
      November 01, 2008 - We asked him to speak with us about how research on UTI prevention provides broader lessons for patient … November 8, 2023 Lessons learned in implementing a chronic opioid therapy management

2856. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care | PSNet
      psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
      September 09, 2013 - October 27, 2010 Project BOOST implementation: lessons learned.

2857. A Weighty Mistake | PSNet
      psnet.ahrq.gov/web-mm/weighty-mistake
      September 01, 2016 - May 12, 2021 Lessons learned from a systems approach to engaging patients and families

2858. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet
      psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
      March 01, 2004 - April 1, 2016 Implementing hospital-based communication-and-resolution programs: lessons … learned in New York City.

2859. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49490/psn-pdf
      September 01, 2005 - mix-ups—creative answers can be found nearly everywhere (eg, even bartender equipment might hold design lessons

2860. Measuring Patient Safety | PSNet
      psnet.ahrq.gov/perspective/measuring-patient-safety
      December 14, 2022 - However, we all know that healthcare requires data which is timely and interoperable; we certainly learned … establishing the systems of safety and those key tools of high-reliability organizations that we have learned … There are many lessons here, including communication strategies, culture, leadership, teamwork training