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Showing results for "lessons learned".

2961. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
      January 01, 2024 - The lesson to be learned in this case is in follow-up care, which as noted above, is not guided by high-grade

2962. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33869/psn-pdf
      November 01, 2018 - In Conversation With… David Meltzer, MD, PhD November 1, 2018 In Conversation With… David Meltzer, MD, PhD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd Editor's note: Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medici…

2963. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet
      psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
      May 01, 2018 - August 21, 2007 Perspective Rapid Response Teams: Lessons

2964. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet
      psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
      January 13, 2010 - September 27, 2023 Designing an abstraction instrument: lessons from efforts to

2965. Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care | PSNet
      psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
      December 23, 2020 - cancer patients. 27 Treatment planning as an on-going process, not a one-time decision  A final lesson learned

2966. The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis | PSNet
      psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
      February 26, 2025 - Rapid response to crisis: health system lessons from the active period of COVID-19.

2967. Discharge Instructions in the PACU: Who Remembers? | PSNet
      psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
      August 05, 2009 - September 23, 2020 The Lancet Commission on lessons for the future from the COVID-19

2968. The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance | PSNet
      psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
      April 01, 2010 - Five years after To Err Is Human: what have we learned? JAMA. 2005;293:2384-2390. … January 6, 2010 Reducing health care hazards: lessons from the Commercial Aviation Safety

2969. Operationalizing Patient Safety at Academic Medical Centers | PSNet
      psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
      August 01, 2010 - RS: That's where the toolkit using lessons borrowed from Toyota is so widely applicable.

2970. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74120/psn-pdf
      November 30, 2021 - A final lesson learned from this case is that the patient may have benefited from multiple conversations

2971. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet
      psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
      September 27, 2023 - Hospital Overcrowding August 31, 2022 Designing an abstraction instrument: lessons

2972. Medication Mix-Up Leads to Patient Death | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
      July 08, 2022 - California’s mandatory nurse staffing ratios: key lessons 2 decades in.

2973. July Syndrome | PSNet
      psnet.ahrq.gov/web-mm/july-syndrome
      July 01, 2011 - Enhancing patient safety and resident education during the academic year-end transfer of outpatients: lessons

2974. When the Indications for Drug Administration Blur | PSNet
      psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
      May 26, 2021 - SPOTLIGHT CASE When the Indications for Drug Administration Blur Citation Text: Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation …

2975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33849/psn-pdf
      January 01, 2018 - Are there deeper lessons from what you've observed in how we use our electronic tools than simply that

2976. Burnout | PSNet
      psnet.ahrq.gov/primer/burnout
      November 20, 2024 - The evolving role of the chief wellness officer in the management of crisis by health care systems: lessons

2977. In Conversation With… Richard C. Boothman, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
      March 01, 2012 - learn from our patients' experiences, we should learn from our mistakes, and infuse in our system those lessons … learned as quickly as possible.

2978. Primary Care and Patient Safety: Opportunities at the Interface | PSNet
      psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
      September 28, 2022 - KH: What would you say are some your biggest lessons learned from that engagement? … The other thing that's really important, is that what we've learned during the epidemic is that even … FS: I’ve just learned so much through my recent experiences as the Primary Care Medical Director for … The other interesting thing that I've learned recently was from overseeing a student who has been helping

2979. Disclosure of Medical Error | PSNet
      psnet.ahrq.gov/perspective/disclosure-medical-error
      January 01, 2009 - Those last two matter a lot to patients because they want to sense that a lesson has been learned from … RW: What have you learned about providers' needs in terms of training? … October 14, 2020 Apology laws and malpractice liability: what have we learned?

2980. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error | PSNet
      psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
      July 30, 2020 - Safety of Older Adults Residing in Nursing Homes February 24, 2022 Editor's Picks Lessons … Learned from the COVID-19 Pandemic to Improve Diagnosis.