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psnet.ahrq.gov/issue/organizational-learning-starting-points-and-presuppositions-case-study-hospitals-surgical
September 25, 2024 - This qualitative study focuses on the starting points and presuppositions of organizational learning
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psnet.ahrq.gov/issue/concept-analysis-systems-thinking
August 20, 2018 - Systems thinking focuses on enabling an organization to learn from experience to address complex problems
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psnet.ahrq.gov/issue/enhancing-healthcare-process-design-human-factors-engineering-and-reliability-science-part-1
October 17, 2018 - This article focuses on human factors and system reliability as building blocks to clinical process design
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psnet.ahrq.gov/issue/toolkit-engage-high-risk-patients-safe-transitions-across-ambulatory-settings
March 11, 2017 - This toolkit focuses on patient transitions between ambulatory care environments and encourages staff
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psnet.ahrq.gov/issue/setting-priorities-patient-safety-ethics-accountability-and-public-engagement
September 29, 2017 - This commentary focuses on the challenge of prioritizing strategies to reduce medical errors and advocates
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psnet.ahrq.gov/issue/what-about-doctors-impact-medical-errors-0
December 15, 2014 - This commentary focuses on physicians as second victims and how mistakes influence their emotional
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psnet.ahrq.gov/issue/patient-safety-helping-medical-students-understand-error-healthcare
December 16, 2009 - This study describes the development and implementation of a medical student curriculum that focuses
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psnet.ahrq.gov/issue/training-hospital-staff-respond-mass-casualty-incident-summary-evidence-reporttechnology
December 24, 2008 - This report focuses on the effectiveness of hospital disaster drills, computer simulations, and tabletop
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psnet.ahrq.gov/issue/errors-medicine-and-law
August 06, 2016 - suggest that most errors are due to systems factors, not moral lapses, and thus the tort system, which focuses
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psnet.ahrq.gov/issue/national-center-patient-safety-ncps
March 27, 2005 - It focuses on prevention rather than punishment by applying human factors analysis and the safety research
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psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health
October 11, 2016 - This book examines one hospital's approach that focuses on safety culture , process improvement , and
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psnet.ahrq.gov/issue/beyond-corrective-action-hierarchy-systems-approach-organizational-change
March 10, 2021 - discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses
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psnet.ahrq.gov/issue/nurses-and-nursing-students-second-victims-scoping-review
March 08, 2023 - scoping review found that majority of the literature on nurses and nursing students as second victims focuses
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psnet.ahrq.gov/issue/safety-ii-behavior-pediatric-intensive-care-unit
January 12, 2022 - Safety-II is characterized by a more proactive approach that focuses on ensuring actions go as planned
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psnet.ahrq.gov/issue/humanizing-harm-using-restorative-approach-heal-and-learn-adverse-events
November 30, 2022 - A restorative approach focuses on (1) who has been hurt and their needs, and who is responsible for addressing
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psnet.ahrq.gov/issue/effectiveness-tele-triage-during-covid-19-pandemic-systematic-review-and-narrative-synthesis
February 01, 2023 - This review of remote triage focuses exclusively on tele-triage studies conducted during the COVID-
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psnet.ahrq.gov/issue/design-evidence-based-second-victim-curriculum-nurse-anesthetists
February 15, 2023 - anesthetists , this commentary describes the development of a curriculum for this specialty group which focuses
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psnet.ahrq.gov/issue/how-physicians-think-case-based-diagnostic-simulation-exercise
August 14, 2019 - achieved the correct diagnosis (herpes zoster) utilized systems-based or anatomic approaches, rather than focuses
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psnet.ahrq.gov/issue/plans-are-worthless-planning-everything-advancing-patient-safety-better-managing-paradox
September 23, 2020 - The Safety-II principle focuses on learning from what goes right in the healthcare system.
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psnet.ahrq.gov/issue/redesigning-rounds-towards-more-purposeful-approach-inpatient-teaching-and-learning
February 02, 2022 - This commentary describes a rounding process that focuses on enhancing safety culture , engaging patients