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341. Psn-Pdf (pdf file)
     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

342. Psn-Pdf (pdf file)
     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

343. Psn-Pdf (pdf file)
     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

344. Psn-Pdf (pdf file)
     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

345. Psn-Pdf (pdf file)
     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

346. Psn-Pdf (pdf file)
     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

347. Psn-Pdf (pdf file)
     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:/

348. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
     July 01, 2012 - Simulation-based education with mastery learning improves residents' lumbar puncture skills. … Simulation-based education with mastery learning improves paracentesis skills. … Mastery Learning: Theory and Practice. New York, NY: Holt, Rinehart, and Winston; 1971. … (SBML) uses simulation with the mastery learning model * * Simulation-Based Mastery Learning … Simulation-based education with mastery learning improves paracentesis skills.

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43863/psn-pdf
     July 16, 2015 - Learning through simulated independent practice leads to better future performance in a simulated crisis … than learning through simulated supervised practice. … Learning through simulated independent practice leads to better future performance in a simulated crisis … than learning through simulated supervised practice. … https://psnet.ahrq.gov/issue/learning-through-simulated-independent-practice-leads-better-future- performance-simulated

350. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47106/psn-pdf
     August 15, 2018 - Imitating incidents: how simulation can improve safety investigation and learning from adverse events … Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From Adverse Events … https://psnet.ahrq.gov/issue/imitating-incidents-how-simulation-can-improve-safety-investigation-and- learning-adverse … strategies to integrate simulation into care routines to optimize cross-functional organizational learning … https://psnet.ahrq.gov/issue/imitating-incidents-how-simulation-can-improve-safety-investigation-and-learning-adverse

351. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45627/psn-pdf
     April 26, 2017 - Imperfect practice makes perfect: error management training improves transfer of learning. … Imperfect practice makes perfect: error management training improves transfer of learning. … psnet.ahrq.gov/issue/imperfect-practice-makes-perfect-error-management-training-improves- transfer-learning … //psnet.ahrq.gov/issue/imperfect-practice-makes-perfect-error-management-training-improves-transfer-learning … //psnet.ahrq.gov/issue/imperfect-practice-makes-perfect-error-management-training-improves-transfer-learning

352. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46844/psn-pdf
     March 07, 2018 - Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience. … Learning Collaboratives: Insights And A New Taxonomy From AHRQ's Two Decades Of Experience. … https://psnet.ahrq.gov/issue/learning-collaboratives-insights-and-new-taxonomy-ahrqs-two-decades- experience … Learning collaboratives are multimodal interventions that are often used to implement evidence-based … The authors suggest that efforts to evaluate learning collaboratives or quality improvement interventions

353. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47479/psn-pdf
     December 12, 2018 - "Closing the loop": a mixed-methods study about resident learning from outcome feedback after patient … "Closing the loop": a mixed-methods study about resident learning from outcome feedback after patient … https://psnet.ahrq.gov/issue/closing-loop-mixed-methods-study-about-resident-learning-outcome-feedback … after-patient Seeking feedback on patient outcomes after a patient handoff takes place may provide useful learning … identified both a lack of time and inadequate systems for tracking patients as significant barriers to learning

354. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44043/psn-pdf
     September 20, 2017 - Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting … Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting … https://psnet.ahrq.gov/issue/incident-learning-pursuit-high-reliability-implementing-comprehensive-low … - threshold-reporting This study describes the experience of an incident learning program in a radiation … https://psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system https://psnet.ahrq.gov/issue

355. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46467/psn-pdf
     October 18, 2017 - The Role of Clinical Learning Environments in Preparing New Clinicians to Engage in Patient Safety. … Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical Learning … https://psnet.ahrq.gov/issue/role-clinical-learning-environments-preparing-new-clinicians-engage-patient … - safety Incorporating patient safety in education and learning environments can augment physician … https://psnet.ahrq.gov/issue/role-clinical-learning-environments-preparing-new-clinicians-engage-patient-safety

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38000/psn-pdf
     August 03, 2009 - The competitive imperative of learning. August 3, 2009 Edmondson A. … The competitive imperative of learning. Harv Bus Rev. 2008;86(7-8):60-7, 160. … https://psnet.ahrq.gov/issue/competitive-imperative-learning This article draws on experience analyzing … team behavior in hospitals to discuss how learning processes can help organizations execute tasks effectively … https://psnet.ahrq.gov/issue/competitive-imperative-learning https://psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and

357. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35934/psn-pdf
     February 24, 2011 - Learning from mistakes: factors that influence how students and residents learn from medical errors. … Learning from mistakes. … https://psnet.ahrq.gov/issue/learning-mistakes-factors-influence-how-students-and-residents-learn-medical … nearly 60 structured interviews with medical trainees and categorized the factors that influenced their learning … The authors discuss recommendations and specific educational methods that may promote improved learning

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37557/psn-pdf
     February 27, 2008 - Learning from patient safety incidents: creating participative risk regulation in healthcare. … Learning from patient safety incidents: Creating participative risk regulation in healthcare. … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-creating-participative-risk-regulation … commentary addresses the importance of involving front-line personnel in patient safety reporting and learning … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-creating-participative-risk-regulation-healthcare

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43003/psn-pdf
     March 05, 2014 - Learning from every death. March 5, 2014 Huddleston JM, Diedrich DA, Kinsey GC, et al. … Learning from every death. J Patient Saf. 2014;10(1):6-12. doi:10.1097/PTS.0000000000000053. … https://psnet.ahrq.gov/issue/learning-every-death This commentary describes how design and implementation … The reporting program offers insights about how to promote and enhance organizational learning. … https://psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40119/psn-pdf
     January 05, 2011 - Effects of learning climate and registered nurse staffing on medication errors. … Effects of Learning Climate and Registered Nurse Staffing on Medication Errors. … https://psnet.ahrq.gov/issue/effects-learning-climate-and-registered-nurse-staffing-medication-errors … The learning climate (a component of safety culture that measures communication between providers) was … https://psnet.ahrq.gov/issue/effects-learning-climate-and-registered-nurse-staffing-medication-errors