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Total Results: 3,005 records

Showing results for "lessons learned".

  1. 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.

  2. 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 ?

  3. 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

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49825/psn-pdf
    April 01, 2018 - The provider learned that the patient was having symptoms concerning for unstable angina and determined … Achieving quality in health care through language access services: lessons from a California public

  5. 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.

  6. 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

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33752/psn-pdf
    August 01, 2013 - We learned along the way that teamwork is important. … RW: Aside from the issue of resilience and readiness of the providers, what else have we learned about … There were places where they would shut down the OR or the ED, and I think that that lesson has been learned

  8. After-Visit Confusion | PSNet

    psnet.ahrq.gov/web-mm/after-visit-confusion
    August 21, 2007 - August 21, 2007 Perspective Rapid Response Teams: Lessons

  9. The Wrong Channel | PSNet

    psnet.ahrq.gov/web-mm/wrong-channel
    February 01, 2003 - mix-ups—creative answers can be found nearly everywhere (eg, even bartender equipment might hold design lessons

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33606/psn-pdf
    December 15, 2024 - opioid-prescribing-decreases-after-learning-patients-fatal-overdose https://psnet.ahrq.gov/issue/addressing-opioid-epidemic-united-states-lessons-department-veterans-affairs

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - California’s mandatory nurse staffing ratios: key lessons 2 decades in. … .2021.103110 https://www.beckershospitalreview.com/nursing/californias-mandatory-nurse-staffing-ratios-key-lessons

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - They are free lessons about how things go wrong and how they can be fixed before someone gets hurt. … Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.

  13. In Conversation With… J. Bryan Sexton, PhD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
    February 26, 2025 - We learned along the way that teamwork is important. … RW : Aside from the issue of resilience and readiness of the providers, what else have we learned about … There were places where they would shut down the OR or the ED, and I think that that lesson has been learned … PhD February 1, 2014 Perspective What We've Learned

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73104/psn-pdf
    January 04, 2021 - Researchers have also learned through disease surveillance that COVID-19 disproportionately affects … epidemiology-and-risk-factors-coronavirus-infection-health-care-workers-living-rapid-review https://psnet.ahrq.gov/issue/lessons-walking-medical-distancing-tightrope … acr-recommendations-use-chest-radiography-and-computed-tomography-ct-suspected-covid-19 https://psnet.ahrq.gov/issue/patient-safety-recommendations-covid-19-epidemic-outbreak-lessons-italian-experience … https://psnet.ahrq.gov/issue/patient-safety-recommendations-covid-19-epidemic-outbreak-lessons-italian-experience

  15. The Ongoing Journey to Prevent Patient Falls | PSNet

    psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
    December 18, 2024 - The Ongoing Journey to Prevent Patient Falls Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD | December 18, 2024  Also Read the Conversation View more articles from the same authors. Citation Text: Dykes PC, Sousane Z, Mossb…

  16. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls | PSNet

    psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
    December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD | December 18, 2024  Also Read the Essay View more articles from the same authors. Citation…

  17. In Conversation with…Jack Barker, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withjack-barker-phd
    January 01, 2006 - RW: How has your training program evolved and what lessons have you learned as you've actually gone … Certainly there are some technical things that could be learned, but because of the current state of

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49632/psn-pdf
    July 01, 2011 - Enhancing patient safety and resident education during the academic year- end transfer of outpatients: lessons

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - Lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365-70.[ go to PubMed ] 2.

  20. Overuse as a Patient Safety Problem | PSNet

    psnet.ahrq.gov/perspective/overuse-patient-safety-problem
    September 01, 2014 - Perspective African Partnerships for Patient Safety: Lessons … Learned December 1, 2014 Perspective Beyond
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