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psnet.ahrq.gov/node/50795/psn-pdf
January 15, 2020 - Diagnostic error in the emergency department: learning
from national patient safety incident report … Diagnostic error in the emergency department: learning
from national patient safety incident report … https://psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety- … https://psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report … https://psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report
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psnet.ahrq.gov/node/72575/psn-pdf
January 01, 2021 - Missing the near miss: recognizing valuable learning
opportunities in radiation oncology. … Missing the near miss: recognizing valuable learning opportunities in
radiation oncology. … https://psnet.ahrq.gov/issue/missing-near-miss-recognizing-valuable-learning-opportunities-radiation- … https://psnet.ahrq.gov/issue/missing-near-miss-recognizing-valuable-learning-opportunities-radiation-oncology … https://psnet.ahrq.gov/issue/missing-near-miss-recognizing-valuable-learning-opportunities-radiation-oncology
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psnet.ahrq.gov/node/47143/psn-pdf
January 30, 2019 - E-learning on risk management. … E-learning on risk management. … https://psnet.ahrq.gov/issue/e-learning-risk-management-opportunity-sharing-knowledge-and-experiences … https://psnet.ahrq.gov/issue/e-learning-risk-management-opportunity-sharing-knowledge-and-experiences-patient-safety … https://psnet.ahrq.gov/issue/e-learning-risk-management-opportunity-sharing-knowledge-and-experiences-patient-safety
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psnet.ahrq.gov/node/837210/psn-pdf
May 25, 2022 - A learning health system agenda for organizational
approaches to enhancing occupational well-being among … A learning health system agenda for organizational approaches to
enhancing occupational well-being among … https://psnet.ahrq.gov/issue/learning-health-system-agenda-organizational-approaches-enhancing-
occupational-well-being … https://psnet.ahrq.gov/issue/learning-health-system-agenda-organizational-approaches-enhancing-occupational-well-being … https://psnet.ahrq.gov/issue/learning-health-system-agenda-organizational-approaches-enhancing-occupational-well-being
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psnet.ahrq.gov/node/42804/psn-pdf
December 11, 2013 - The costs of developing, implementing, and operating a
safety learning system in community practice. … The costs of developing, implementing, and operating a safety
learning system in community practice. … This study estimated a cost of approximately CAD $260,000 over 4 years to develop and run a safety
learning … https://psnet.ahrq.gov/issue/safety-learning-system-development-incident-reporting-component-family-practice … https://psnet.ahrq.gov/issue/safety-learning-system-development-incident-reporting-component-family-practice
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psnet.ahrq.gov/node/43681/psn-pdf
June 03, 2016 - Learning from failure: the need for independent safety
investigation in healthcare. … Learning from failure: the need for independent safety investigation in healthcare. … https://psnet.ahrq.gov/issue/learning-failure-need-independent-safety-investigation-healthcare
High … To promote learning and improve health care safety in
the United Kingdom, this commentary recommends … //psnet.ahrq.gov/issue/strategies-learning-failure
https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical
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psnet.ahrq.gov/node/40365/psn-pdf
February 12, 2014 - Strategies for learning from failure.
February 12, 2014
Edmondson A. … Strategies of learning from failure. Harv Bus Rev. 2011;89(4):48-55, 137. … https://psnet.ahrq.gov/issue/strategies-learning-failure
Failures are inevitable in any industry, especially … characteristic of high reliability organizations, and creating a climate that emphasizes
organizational learning … unavoidable failures in complex organizations, which should be
reported, analyzed, and treated as learning
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psnet.ahrq.gov/node/40955/psn-pdf
March 08, 2017 - Kaiser Permanente's performance improvement system,
part 4: creating a learning organization. … Kaiser Permanente's performance improvement system, Part 4:
Creating a learning organization. … https://psnet.ahrq.gov/issue/kaiser-permanentes-performance-improvement-system-part-4-creating-
learning-organization … article discusses Kaiser Permanente's efforts to develop a performance improvement system and
become a learning … https://psnet.ahrq.gov/issue/building-learning-organization
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psnet.ahrq.gov/node/73182/psn-pdf
April 28, 2021 - Learning from morbidity and mortality conferences: focus
and sustainability of lessons for patient care … Learning from morbidity and mortality conferences:
focus and sustainability of lessons for patient care … https://psnet.ahrq.gov/issue/learning-morbidity-and-mortality-conferences-focus-and-sustainability-lessons … https://psnet.ahrq.gov/issue/learning-morbidity-and-mortality-conferences-focus-and-sustainability-lessons-patient-care … https://psnet.ahrq.gov/issue/learning-morbidity-and-mortality-conferences-focus-and-sustainability-lessons-patient-care
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psnet.ahrq.gov/node/847720/psn-pdf
April 19, 2023 - In situ simulation-based team training and its significance
for transfer of learning to clinical practice … In situ simulation-based team training and its significance for
transfer of learning to clinical practice … https://psnet.ahrq.gov/issue/situ-simulation-based-team-training-and-its-significance-transfer-learning … https://psnet.ahrq.gov/issue/situ-simulation-based-team-training-and-its-significance-transfer-learning-clinical-practice … https://psnet.ahrq.gov/issue/situ-simulation-based-team-training-and-its-significance-transfer-learning-clinical-practice
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psnet.ahrq.gov/node/73633/psn-pdf
August 25, 2021 - Learning from patient safety incidents involving acutely
sick adults in hospital assessment units in … Learning from patient safety incidents involving acutely sick adults
in hospital assessment units in … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-involving-acutely-sick-adults-hospital … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-involving-acutely-sick-adults-hospital-assessment-units … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-involving-acutely-sick-adults-hospital-assessment-units
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psnet.ahrq.gov/node/47806/psn-pdf
January 01, 2021 - analysis through postimplementation evaluation can
lead to solutions grounded in actual practice and learning … This
commentary discusses the Agency for Healthcare Research and Quality patient safety learning laboratories … challenges-and-opportunities-improving-patient-safety-through-human-factors-and-systems
https://psnet.ahrq.gov/issue/best-care-lower-cost-path-continuously-learning-health-care-america … https://psnet.ahrq.gov/issue/overview-patient-safety-learning-laboratory-projects
https://psnet.ahrq.gov … /issue/overview-patient-safety-learning-laboratory-projects
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psnet.ahrq.gov/node/73350/psn-pdf
June 02, 2021 - Learning during crisis: the impact of COVID-19 on
hospital-acquired pressure injury incidence. … Learning during crisis: the impact of COVID-19 on hospital-acquired
pressure injury incidence. … https://psnet.ahrq.gov/issue/learning-during-crisis-impact-covid-19-hospital-acquired-pressure-injury … https://psnet.ahrq.gov/issue/learning-during-crisis-impact-covid-19-hospital-acquired-pressure-injury-incidence … https://psnet.ahrq.gov/issue/learning-during-crisis-impact-covid-19-hospital-acquired-pressure-injury-incidence
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psnet.ahrq.gov/node/41153/psn-pdf
January 01, 2013 - Quality improvement for patient safety: project-level
versus program-level learning. … Quality improvement for patient safety: project-level versus program-
level learning. … https://psnet.ahrq.gov/issue/quality-improvement-patient-safety-project-level-versus-program-level-learning … understand factors behind
the success of quality improvement programs and found that program-level learning … https://psnet.ahrq.gov/issue/building-learning-organization
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psnet.ahrq.gov/node/47548/psn-pdf
July 17, 2019 - Patient Safety Learning.
July 17, 2019
Patient Safety Learning. … https://psnet.ahrq.gov/issue/patient-safety-learning
This website shares system-focused approaches to … https://psnet.ahrq.gov/issue/patient-safety-learning
https://psnet.ahrq.gov/primer/systems-approach
https
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psnet.ahrq.gov/node/36378/psn-pdf
October 28, 2010 - Teaching but not learning: how medical residency
programs handle errors. … Teaching but not learning: how medical residency programs handle errors. … https://psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-programs-handle-errors
This … https://psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-programs-handle-errors
https … https://psnet.ahrq.gov/issue/residents-responses-medical-error-coping-learning-and-change
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psnet.ahrq.gov/node/764401/psn-pdf
March 02, 2022 - Promoting patient and nurse safety: testing a behavioural
health intervention in a learning healthcare … Promoting patient and nurse safety: testing a behavioural
health intervention in a learning healthcare … //psnet.ahrq.gov/issue/promoting-patient-and-nurse-safety-testing-behavioural-health-intervention-
learning … https://psnet.ahrq.gov/issue/promoting-patient-and-nurse-safety-testing-behavioural-health-intervention-learning … https://psnet.ahrq.gov/issue/promoting-patient-and-nurse-safety-testing-behavioural-health-intervention-learning
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psnet.ahrq.gov/node/46640/psn-pdf
August 08, 2018 - IDEA4PS: the development of a research-oriented
learning healthcare system. … IDEA4PS: The Development of a Research-Oriented
Learning Healthcare System. … https://psnet.ahrq.gov/issue/idea4ps-development-research-oriented-learning-healthcare-system
Collaborating … to implement rapid-cycle learning is a strategy to design and sustain patient safety
innovations. … https://psnet.ahrq.gov/issue/idea4ps-development-research-oriented-learning-healthcare-system
https:/
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psnet.ahrq.gov/node/74230/psn-pdf
January 12, 2022 - Learning from diagnostic errors to improve patient safety
when GPs work in or alongside emergency departments … Learning from diagnostic errors to improve patient safety
when GPs work in or alongside emergency departments … https://psnet.ahrq.gov/issue/learning-diagnostic-errors-improve-patient-safety-when-gps-work-or-alongside … https://psnet.ahrq.gov/issue/learning-diagnostic-errors-improve-patient-safety-when-gps-work-or-alongside-emergency … https://psnet.ahrq.gov/issue/learning-diagnostic-errors-improve-patient-safety-when-gps-work-or-alongside-emergency
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psnet.ahrq.gov/node/45580/psn-pdf
July 24, 2019 - Overview of Patient Safety Learning Laboratory Projects. … https://psnet.ahrq.gov/issue/overview-patient-safety-learning-laboratory-projects
Collaborative strategies … Agency for Healthcare
Research and Quality funding designed for rapid deployment through team-focused learning … https://psnet.ahrq.gov/issue/overview-patient-safety-learning-laboratory-projects
https://psnet.ahrq.gov