lzipperer
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Nice summary Helen. Congrats to colleagues in the UK for what has been accomplished and all the best for making progress on the rest.
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thanks to the hub for including our article here. I'd love to hear from clinicians as to the usefulness of the concepts we shared.
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here are some examples of PSnet materials generated from case submissions: https://psnet.ahrq.gov/webmm-case-studies
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Thank you @Helen and to all hub members for their continued contributions to the work of improving patient safety!
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An important source and concept for us to consider in these trying times.
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Richard -- Congrats on your success in these challenging times. I hope to see more of your story on the hub!
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Here is a link to the bias webinar I mention in the March webinar: https://register.gotowebinar.com/recording/5627630769960041484 you should be able to get at it just by filling out the form.
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This post reminded me of John Nance's book "Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care". Worth a read in its entirely -- but here is a nice excerpt. https://abcnews.go.com/GMA/Books/story?id=7319785&page=1
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Thank you to the reporter for sharing this story. I am saddened that 20 years after To Err is Human and subsequently An Organisation with a Memory this sort of response still occurs. I am troubled by the leadership failure here!
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Thanks for posting this. Always worth seeing what Charles Vincent has to say! Its in my pile to read.
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Jules -- thanks for sharing this. I have heard from colleagues that systematic reviews aren't always that useful in day-to-day practice. How would you suggest they use this material to further their efforts on the front line to generate the use of simulation?
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Judy -- you have nicely summarized how AARs serve as a source of knowledge sharing to help organizations learn--but I am not sure how they are optimized to do that in a real "human-centered" rather than "information sharing" way. Just developing and disseminating a report is a good thing, but the tacit knowledge that makes the AARs potentially so powerful as learning opportunities can get lost when the discussions are translated to an explicit object.
How has your experience made AARs into a true knowledge transfer strategy throughout an organization?
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'The PSIRF Hollywood collaborative': a blog from Jane Carthey, Tracey Herlihey, Claire Cox, Maureen Bankole-Allibay and Helen Hughes
in Patient Safety Incident Response Framework (PSIRF)
Posted
very fun...reminds me of a few of the Letters from America 😉