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Total Results: 3,236 records

Showing results for "lessons learned".

2921. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-442
      May 29, 2024 - Study Lessons learned from a national hospital antibiotic stewardship implementation

2922. Triage Time Bomb | PSNet
      psnet.ahrq.gov/web-mm/triage-time-bomb
      September 01, 2008 - Failure to Latch September 1, 2008 Changing smart pump vendors: lessons … learned.

2923. Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner | PSNet
      psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
      February 26, 2025 - Anesthesia adverse events voluntarily reported in the Veterans health administration and lessons learned

2924. Reconciling Records | PSNet
      psnet.ahrq.gov/web-mm/reconciling-records
      September 01, 2017 - Initial lessons from the first national demonstration project on practice transformation to a patient-centered … Perspective Assessing the Safety of Electronic Health Records: What Have We Learned

2925. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - 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

2926. An Obstructed View | PSNet
      psnet.ahrq.gov/web-mm/obstructed-view
      August 07, 2019 - January 10, 2024 Patients' perspectives on quality and patient safety failures: lessons … learned from an inquiry into transvaginal mesh in Australia.

2927. Missing Trauma | PSNet
      psnet.ahrq.gov/web-mm/missing-trauma
      March 03, 2011 - Resources From the Same Author(s) Patterns of errors contributing to trauma mortality: lessons … learned from 2,594 deaths.

2928. Medication Reconciliation Victory After an Avoidable Error | PSNet
      psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
      April 01, 2015 - August 14, 2024 Exploring the impact of safety culture on incident reporting: lessons … learned from machine learning analysis of NHS England staff survey and incident data.

2929. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850678/psn-pdf
      June 14, 2023 - The lessons learned from the pilot were then applied to a staggered deployment of the innovation to

2930. The nature of surgical error: a cautionary tale and a call to reason. | PSNet
      psnet.ahrq.gov/issue/nature-surgical-error-cautionary-tale-and-call-reason
      September 12, 2007 - 2022 Disclosing large scale adverse events in the US Veterans Health Administration: lessons … November 6, 2019 Reducing health care hazards: lessons from the Commercial Aviation Safety … Lessons from aviation for returning to non-urgent surgery following COVID-19.

2931. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33638/psn-pdf
      August 01, 2006 - I learned an important lesson: enlightened, risk-taking leadership is the only way to achieve significant

2932. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33820/psn-pdf
      December 01, 2016 - 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

2933. Workplace Safety in Health Care | PSNet
      psnet.ahrq.gov/perspective/workplace-safety-health-care
      January 01, 2017 - To build a better hospital, Virginia Mason takes lessons from Toyota plants. Seattle PI. … themselves discovered that, because they had all gone to different nursing schools and thought they had learned … PO : I think there are more businesses that have learned the ideas of continuous learning and continuous … demonstrated things in my own work environments when I was Secretary of the Treasury that I had first learned … One thing I've learned in health and medical care is they have this wonderful dodge; if you hurt your

2934. In Conversation With… Paul H. O'Neill, MPA | PSNet
      psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
      January 01, 2017 - themselves discovered that, because they had all gone to different nursing schools and thought they had learned … PO : I think there are more businesses that have learned the ideas of continuous learning and continuous … demonstrated things in my own work environments when I was Secretary of the Treasury that I had first learned … One thing I've learned in health and medical care is they have this wonderful dodge; if you hurt your … To build a better hospital, Virginia Mason takes lessons from Toyota plants. Seattle PI.

2935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840174/psn-pdf
      August 28, 2024 - was no plan or commitment made to the widow to follow up with her and further explain what was later learned … The lessons learned and improvements made in response to the adverse event should also be explained,

2936. Missed CANDOR Implementation Opportunities. | PSNet
      psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
      November 11, 2020 - was no plan or commitment made to the widow to follow up with her and further explain what was later learned … The lessons learned and improvements made in response to the adverse event should also be explained,

2937. Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income Seniors and other High-Risk Populations | PSNet
      psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
      July 23, 2024 - Geriatric Resources for Assessment and Care of Elders Team Care in a Veterans Affairs Medical Center: Lessons … Learned and Effects Observed. … Geriatric Resources for Assessment and Care of Elders Team Care in a Veterans Affairs Medical Center: Lessons … Learned and Effects Observed.

2938. Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area | PSNet
      psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
      November 13, 2024 - Over its 17 years in operation, the High-Risk Pregnancy Program has gained a number of valuable lessons … learned that are particularly advantageous when reviewing this innovation for replication in other areas … The following lessons learned offer guidance in launching and sustaining this innovation: Identify

2939. Diagnostic errors in medicine: a case of neglect. | PSNet
      psnet.ahrq.gov/issue/diagnostic-errors-medicine-case-neglect
      July 15, 2015 - August 28, 2019 Evidence that nurses need to participate in diagnosis: lessons from malpractice

2940. Impact of medical mistakes: navigating work–family boundaries for physicians and their families. | PSNet
      psnet.ahrq.gov/issue/impact-medical-mistakes-navigating-work-family-boundaries-physicians-and-their-families
      January 23, 2019 - February 27, 2008 Lessons in Patient Safety. … Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons