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Total Results: 3,236 records

Showing results for "lessons learned".

2981. Patient Safety and Health Information Technology: Learning from Our Mistakes | PSNet
      psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
      July 01, 2012 - equals patient safety, and more health IT equals more patient safety .( 7 ) Paradoxically, we've learned … H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations. … DB : What I learned was that whenever a lot of money is made available by our government for anything … So there were a whole series of things that I learned in Washington that are applicable even in this

2982. In Conversation With… David Blumenthal, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
      July 01, 2012 - DB : What I learned was that whenever a lot of money is made available by our government for anything … So there were a whole series of things that I learned in Washington that are applicable even in this … equals patient safety, and more health IT equals more patient safety .( 7 ) Paradoxically, we've learned … H.I.T. or Miss: Lessons Learned from Health Information Technology Implementations.

2983. In Conversation With... James P. Bagian, MD, PE | PSNet
      psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
      February 26, 2025 - 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

2984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33841/psn-pdf
      September 01, 2017 - We've learned that even really well-designed software can be made very challenging for clinicians when … One of the key lessons is to be more of a learning system all the way through. AG: Absolutely.

2985. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
      November 01, 2011 - Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.

2986. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33861/psn-pdf
      July 01, 2018 - RW: What have we learned in the last 5 or 10 years about trying to measure diagnostic errors? … We've been looking at malpractice cases for lessons. … One thing we've learned is that stories are very important.

2987. Preventable Transfer to the Hospital | PSNet
      psnet.ahrq.gov/web-mm/preventable-transfer-hospital
      March 31, 2022 - Root cause analyses of transfers of skilled nursing facility patients to acute hospitals: lessons learned

2988. DRESSed for Failure | PSNet
      psnet.ahrq.gov/web-mm/dressed-failure
      September 01, 2011 - The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons … learned from a multisite qualitative study.

2989. Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration | PSNet
      psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
      October 30, 2024 - The lessons learned from the pilot were then applied to a staggered deployment of the innovation to an

2990. Liposuction Gone Awry | PSNet
      psnet.ahrq.gov/web-mm/liposuction-gone-awry
      July 01, 2003 - Routine Goes Awry June 1, 2011 Adverse event reporting: lessons … learned from 4 years of Florida office data.

2991. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - August 5, 2009 The safety journal: lessons learned with an error reporting tool to stimulate

2992. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-422
      January 04, 2024 - what has happened; learning from the factual; learning from experience; knowing how to learn the right lessons

2993. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-327
      February 23, 2022 - Challenges, facilitators, and lessons learned are discussed.

2994. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. | PSNet
      psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
      August 25, 2021 - Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Lessons … learned in implementing a chronic opioid therapy management system.

2995. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
      August 01, 2009 - many academic and consumer articles, which focus on optimizing organizational effectiveness through lessons … While rivals were in the mindset of planning, command, and control, Toyota had learned that no amount … several months, they started tackling this problem, these constant breakdowns in care, in the ways we learned … These people often find that there are so many disanalogies that the lessons aren't transferable.

2996. Workarounds and Resiliency on the Front Lines of Health Care | PSNet
      psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
      August 01, 2009 - many academic and consumer articles, which focus on optimizing organizational effectiveness through lessons … While rivals were in the mindset of planning, command, and control, Toyota had learned that no amount … several months, they started tackling this problem, these constant breakdowns in care, in the ways we learned … These people often find that there are so many disanalogies that the lessons aren't transferable.

2997. EHR Copy and Paste and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
      January 01, 2018 - Duly noted: lessons from a two-site intervention to assess and improve the quality of clinical documentation … Are there deeper lessons from what you've observed in how we use our electronic tools than simply that … Perspective Assessing the Safety of Electronic Health Records: What Have We Learned … Perspective Assessing the Safety of Electronic Health Records: What Have We Learned

2998. Training Catalog | PSNet
      psnet.ahrq.gov/Psnet
      April 29, 2021 - Training Catalog The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. Some training opportunities are available as in-person meetings…

2999. ACR White Paper on Magnetic Resonance (MR) Safety: Combined Papers of 2002 and 2004. | PSNet
      psnet.ahrq.gov/issue/acr-white-paper-magnetic-resonance-mr-safety-combined-papers-2002-and-2004
      August 13, 2008 - August 26, 2015 Lessons in Patient Safety.

3000. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-342
      May 16, 2022 - Understanding the factors influencing implementation of a new national patient safety policy in England: lessons