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361. 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

362. 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

363. 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

364. 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

365. 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

366. 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.

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39444/psn-pdf
     June 28, 2010 - The relationship between organizational leadership for safety and learning from patient safety events … The relationship between organizational leadership for safety and learning from patient safety events … https://psnet.ahrq.gov/issue/relationship-between-organizational-leadership-safety-and-learning-patient … This Canadian study sought to quantify the relationship between leadership and organizational learning … https://psnet.ahrq.gov/issue/relationship-between-organizational-leadership-safety-and-learning-patient-safety-events

368. 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

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45058/psn-pdf
     February 18, 2017 - Learning from incidents in healthcare: the journey, not the arrival, matters. … Learning from incidents in healthcare: the journey, not the arrival, matters. … https://psnet.ahrq.gov/issue/learning-incidents-healthcare-journey-not-arrival-matters Experiences from … This commentary describes the Dutch national reporting system effort to encourage individual hospital learning … https://psnet.ahrq.gov/issue/learning-incidents-healthcare-journey-not-arrival-matters https://psnet.ahrq.gov

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42535/psn-pdf
     October 16, 2013 - Implementing an interprofessional patient safety learning initiative: insights from participants, project … Implementing an interprofessional patient safety learning initiative: insights from participants, project … https://psnet.ahrq.gov/issue/implementing-interprofessional-patient-safety-learning-initiative-insights … prominent strategy was stakeholder ownership of a patient safety issue in a supportive interprofessional learning … https://psnet.ahrq.gov/issue/implementing-interprofessional-patient-safety-learning-initiative-insights-participants

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43218/psn-pdf
     July 28, 2014 - Risk management—learning from the mistakes of others. July 28, 2014 Meydan C. … Risk management--learning from the mistakes of others. J Eval Clin Pract. 2014;20(4):505-7. … https://psnet.ahrq.gov/issue/risk-management-learning-mistakes-others This commentary introduces a structured … for case review to help medical students learn risk management strategies and promote organizational learning … psnet.ahrq.gov/issue/principles-risk-management-and-patient-safety https://psnet.ahrq.gov/issue/yours-learning-organization

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40177/psn-pdf
     June 08, 2011 - Learning from disasters to improve patient safety: applying the generic disaster pathway to health system … Learning from disasters to improve patient safety: applying the generic disaster pathway to health system … https://psnet.ahrq.gov/issue/learning-disasters-improve-patient-safety-applying-generic-disaster-pathway … https://psnet.ahrq.gov/issue/learning-disasters-improve-patient-safety-applying-generic-disaster-pathway-health-system … https://psnet.ahrq.gov/issue/bad-stars-or-guiding-lights-learning-disasters-improve-patient-safety https

373. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45502/psn-pdf
     March 01, 2017 - Screening electronic health record–related patient safety reports using machine learning. … Screening Electronic Health Record–Related Patient Safety Reports Using Machine Learning. … psnet.ahrq.gov/issue/screening-electronic-health-record-related-patient-safety-reports-using- machine-learning … This study described the development of a machine learning algorithm to analyze free-text data in incident … psnet.ahrq.gov/issue/screening-electronic-health-record-related-patient-safety-reports-using-machine-learning

374. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44584/psn-pdf
     March 15, 2016 - Barriers to implementing a reporting and learning patient safety system: pediatric chiropractic perspective … Barriers to Implementing a Reporting and Learning Patient Safety System: Pediatric Chiropractic Perspective … https://psnet.ahrq.gov/issue/barriers-implementing-reporting-and-learning-patient-safety-system-pediatric … about patients' responses were the most common barriers to participating in voluntary reporting and learning … https://psnet.ahrq.gov/issue/barriers-implementing-reporting-and-learning-patient-safety-system-pediatric-chiropractic

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44738/psn-pdf
     May 21, 2016 - Thinking About Learning for Improvement in Health Care. May 21, 2016 Lucas B, Nacer H. … https://psnet.ahrq.gov/issue/habits-improver-thinking-about-learning-improvement-health-care Committed … lasting improvements in response to the Francis inquiry, this report discusses a model that focuses on learning … https://psnet.ahrq.gov/issue/habits-improver-thinking-about-learning-improvement-health-care https:// … https://psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43970/psn-pdf
     May 19, 2015 - Organisational reporting and learning systems: innovating inside and outside of the box. … Organisational reporting and learning systems: Innovating inside and outside of the box. … https://psnet.ahrq.gov/issue/organisational-reporting-and-learning-systems-innovating-inside-and-outside … This commentary describes the experiences of two projects aimed at learning from error reports, an internal … https://psnet.ahrq.gov/issue/organisational-reporting-and-learning-systems-innovating-inside-and-outside-box

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44691/psn-pdf
     December 02, 2015 - Quality and safety in orthopaedics: learning and teaching at the same time: AOA critical issues. … Quality and Safety in Orthopaedics: Learning and Teaching at the Same Time: AOA Critical Issues. … https://psnet.ahrq.gov/issue/quality-and-safety-orthopaedics-learning-and-teaching-same-time-aoa-critical … establishing a culture of safety that promotes error prevention, teamwork, transparency, and continuous learning … https://psnet.ahrq.gov/issue/quality-and-safety-orthopaedics-learning-and-teaching-same-time-aoa-critical-issues

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38934/psn-pdf
     June 28, 2011 - Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning … Medication errors: how reliable are the severity ratings reported to the national reporting and learning … psnet.ahrq.gov/issue/medication-errors-how-reliable-are-severity-ratings-reported-national-reporting- and-learning … Assessment of the severity of medication errors reported to the National Reporting and Learning System … psnet.ahrq.gov/issue/medication-errors-how-reliable-are-severity-ratings-reported-national-reporting-and-learning

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42497/psn-pdf
     February 27, 2014 - A prospective study of the link between the ward's learning practices and medication administration … A prospective study of the link between the ward's learning practices and medication administration … https://psnet.ahrq.gov/issue/how-do-we-learn-errors-prospective-study-link-between-wards-learning- practices-and-medication … Supervisory learning, in which senior nurses monitored and provided feedback for junior nurses, was … https://psnet.ahrq.gov/issue/how-do-we-learn-errors-prospective-study-link-between-wards-learning-practices-and-medication

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47080/psn-pdf
     May 02, 2018 - The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations … https://psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many … https://psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many-safety-violations … https://psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many-safety-violations … https://psnet.ahrq.gov/issue/role-clinical-learning-environments-preparing-new-clinicians-engage-patient-safety