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Showing results for "lessons learned".

2941. How human factors lead to medical device adverse events. | PSNet
      psnet.ahrq.gov/issue/how-human-factors-lead-medical-device-adverse-events
      February 10, 2021 - August 3, 2005 Lessons in Patient Safety. … Lessons from aviation for returning to non-urgent surgery following COVID-19.

2942. Brief for the American Hospital Association and Federation of American Hospitals as Amici Curiae Supporting Respondents, Southern Baptist Hospital of Florida, Inc. v. Jean Charles, Jr. No. 16-1446. July 6, 2017. | PSNet
      psnet.ahrq.gov/issue/brief-american-hospital-association-and-federation-american-hospitals-amici-curiae-supporting
      October 24, 2022 - July 16, 2014 Profiles in Excellence: Quality Improvement Lessons--Parts 1 and 2.

2943. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
      August 01, 2015 - information to enable clear identification of patients (and promote patient safety) 15 15 Key Lessons

2944. How Does Infection Prevention Fit Into a Safety Program? | PSNet
      psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
      March 01, 2014 - is worth reflecting on the growth and development of such programs; this history may hold important lessons … What are a few lessons that people in the infection world have learned that might be relevant to patient … Why do you think that difference arose, and are lessons about how the infection world collects evidence

2945. In Conversation With… Alison Holmes, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
      March 01, 2014 - What are a few lessons that people in the infection world have learned that might be relevant to patient … Why do you think that difference arose, and are lessons about how the infection world collects evidence … is worth reflecting on the growth and development of such programs; this history may hold important lessons

2946. Application of Safety-II Principles | PSNet
      psnet.ahrq.gov/perspective/application-safety-ii-principles
      August 28, 2024 - At that conference, we learned from other industries, such as aviation and nuclear power, sharing practical … Sarah Mossburg: Are there any lessons learned or advice that you would provide to other organizations

2947. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet
      psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
      August 28, 2024 - At that conference, we learned from other industries, such as aviation and nuclear power, sharing practical … Sarah Mossburg: Are there any lessons learned or advice that you would provide to other organizations

2948. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. … Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

2949. A Seasonal Care Transition Failure | PSNet
      psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
      June 01, 2016 - Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons … Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons

2950. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up | PSNet
      psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
      December 01, 2005 - But, in the patient safety arena, I found significant challenges, ones that hold lessons for the American … Understanding the factors influencing implementation of a new national patient safety policy in England: lessons

2951. Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
      February 26, 2025 - that may be missed without effective reporting and analysis in combination with dissemination of the lessons … learned. … You just must establish trust with the partners and have the willingness to share what is learned.

2952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33796/psn-pdf
      January 01, 2016 - MG: We didn't know either, but after a few calls to the Institute of Medicine we learned. … Also I'm a huge fan of the AHRQ WebM&M conferences, and there are many, many valuable lessons in there … What I've learned is that IOM reports tend to stay at a very high level, and it's up to the stakeholders

2953. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-406
      August 30, 2023 - Study Exploring the impact of safety culture on incident reporting: lessons learned

2954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846563/psn-pdf
      March 21, 2023 - Lessons learned from adverse events could help improve future patient safety.

2955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33700/psn-pdf
      October 01, 2010 - PP: One of the key lessons that I've learned is that there are different types of problems in safety

2956. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841566/psn-pdf
      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

2957. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-451
      August 28, 2024 - Patient safety organizations (PSOs), such as Wake Up Safe, can aggregate data and share lessons from

2958. Impact of System Failures on Healthcare Workers | PSNet
      psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
      August 30, 2023 - Lessons learned from adverse events could help improve future patient safety.

2959. In Conversation With… Urmimala Sarkar, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
      August 22, 2014 - RW : Are there any other differences that make it hazardous to extrapolate things we've learned from … being partly we've never had the organizational model, partly finances, partly because physicians never learned … RW : You mentioned that some lessons from other industries that seem to be at least somewhat useful in … Are there lessons from other industries that do translate very well to the ambulatory side? … Safety in the Outpatient Setting While much of our progress will come from adapting the things we have learned

2960. Exploring the harmful effects of health care. | PSNet
      psnet.ahrq.gov/issue/exploring-harmful-effects-health-care
      January 25, 2023 - April 4, 2012 Case-based learning for patient safety: the Lessons Learnt program for