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421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34599/psn-pdf
     January 30, 2008 - Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line … Working Paper 4359-02 https://psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem … This paper confronts two central issues for organizational learning from the prism of the chemical and … https://psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line … https://psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line

422. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37996/psn-pdf
     August 20, 2008 - "Every error counts": a web-based incident reporting and learning system for general practice. … "Every error counts": a web-based incident reporting and learning system for general practice. … https://psnet.ahrq.gov/issue/every-error-counts-web-based-incident-reporting-and-learning-system-general … https://psnet.ahrq.gov/issue/every-error-counts-web-based-incident-reporting-and-learning-system-general-practice … https://psnet.ahrq.gov/issue/every-error-counts-web-based-incident-reporting-and-learning-system-general-practice

423. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34669/psn-pdf
     June 26, 2015 - Learning from mistakes is easier said than done: group and organizational influences on the detection … Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences on the Detection … https://psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences- … organization must design and nurture work environments that encourage error reporting and fostering learning … https://psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39802/psn-pdf
     November 16, 2010 - "Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient … "Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient … https://psnet.ahrq.gov/issue/water-cooler-learning-knowledge-sharing-clinical-backstage-and-its- contribution-patient … the forefront, leaving many “water cooler” conversations as a lost opportunity for organizational learning … https://psnet.ahrq.gov/issue/water-cooler-learning-knowledge-sharing-clinical-backstage-and-its-contribution-patient

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45560/psn-pdf
     October 19, 2016 - Learning from excellence in healthcare: a new approach to incident reporting. … Learning from excellence in healthcare: a new approach to incident reporting. … https://psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting Learning … https://psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting https://psnet.ahrq.gov

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34765/psn-pdf
     January 04, 2017 - The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition. … https://psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition … Senge’s seminal and oft-referenced book outlines five competencies that support a learning organization … : systems thinking, personal mastery, mental models, building shared vision, and team learning. … https://psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition

427. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45312/psn-pdf
     July 27, 2016 - Perioperative safety: learning, not taking, from aviation. … Perioperative Safety: Learning, Not Taking, from Aviation. … https://psnet.ahrq.gov/issue/perioperative-safety-learning-not-taking-aviation Although aviation safety … https://psnet.ahrq.gov/issue/perioperative-safety-learning-not-taking-aviation https://psnet.ahrq.gov … aviation-and-healthcare-comparative-review-implications-patient-safety https://psnet.ahrq.gov/primer/checklists https://psnet.ahrq.gov/primer/debriefing-clinical-learning

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41424/psn-pdf
     June 27, 2012 - Practice-based learning and improvement: a two-year experience with the reporting of morbidity and mortality … Practice-based learning and improvement: a two-year experience with the reporting of morbidity and mortality … https://psnet.ahrq.gov/issue/practice-based-learning-and-improvement-two-year-experience-reporting- … https://psnet.ahrq.gov/issue/practice-based-learning-and-improvement-two-year-experience-reporting-morbidity-and-mortality … https://psnet.ahrq.gov/issue/practice-based-learning-and-improvement-two-year-experience-reporting-morbidity-and-mortality

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45612/psn-pdf
     November 09, 2016 - Pharmacist work stress and learning from quality related events. … Pharmacist work stress and learning from quality related events. … https://psnet.ahrq.gov/issue/pharmacist-work-stress-and-learning-quality-related-events High-quality … This survey of community pharmacists found that a blame-free culture promotes learning from error investigation … https://psnet.ahrq.gov/issue/pharmacist-work-stress-and-learning-quality-related-events https://psnet.ahrq.gov

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40608/psn-pdf
     November 27, 2012 - Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning … Developing a 'critical' approach to patient and public involvement in patient safety in the NHS: learning … psnet.ahrq.gov/issue/developing-critical-approach-patient-and-public-involvement-patient-safety- nhs-learning … psnet.ahrq.gov/issue/developing-critical-approach-patient-and-public-involvement-patient-safety-nhs-learning … psnet.ahrq.gov/issue/developing-critical-approach-patient-and-public-involvement-patient-safety-nhs-learning

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43750/psn-pdf
     June 21, 2015 - Using a quantitative risk register to promote learning from a patient safety reporting system. … Using a quantitative risk register to promote learning from a patient safety reporting system. … https://psnet.ahrq.gov/issue/using-quantitative-risk-register-promote-learning-patient-safety-reporting … https://psnet.ahrq.gov/issue/using-quantitative-risk-register-promote-learning-patient-safety-reporting-system … https://psnet.ahrq.gov/issue/using-quantitative-risk-register-promote-learning-patient-safety-reporting-system

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41952/psn-pdf
     January 16, 2013 - Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning … Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning … psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental- incident-learning … psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning … psnet.ahrq.gov/issue/prevention-wrong-location-misadministration-through-use-intradepartmental-incident-learning

433. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46695/psn-pdf
     January 10, 2018 - Predicting the future—big data, machine learning, and clinical medicine. … Predicting the future—big data, machine learning, and clinical medicine. … https://psnet.ahrq.gov/issue/predicting-future-big-data-machine-learning-and-clinical-medicine Medicine … This commentary outlines how machine learning can enable better analysis and application of data and … https://psnet.ahrq.gov/issue/predicting-future-big-data-machine-learning-and-clinical-medicine https:

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41699/psn-pdf
     July 08, 2016 - Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. … Committee on the Learning Health Care System in America, Institute of Medicine. … https://psnet.ahrq.gov/issue/best-care-lower-cost-path-continuously-learning-health-care-america This … It emphasizes the importance of continuous learning—not only from high performing health care systems … https://psnet.ahrq.gov/issue/best-care-lower-cost-path-continuously-learning-health-care-america

435. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47165/psn-pdf
     June 13, 2018 - https://psnet.ahrq.gov/issue/changing-how-we-think-about-healthcare-improvement In learning organizations … , leadership behavior creates a supportive learning environment where concrete processes are in place … to facilitate learning and encourage creativity among employees. … psnet.ahrq.gov/issue/changing-how-we-think-about-healthcare-improvement https://psnet.ahrq.gov/issue/building-learning-organization … psnet.ahrq.gov/issue/quality-improvement-series https://psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46398/psn-pdf
     June 25, 2018 - Challenges in health care simulation: are we learning anything new? … Challenges in Health Care Simulation: Are We Learning Anything New? … https://psnet.ahrq.gov/issue/challenges-health-care-simulation-are-we-learning-anything-new Simulation … The authors encourage research that could help to formalize the evidence base of this promising learning … https://psnet.ahrq.gov/issue/challenges-health-care-simulation-are-we-learning-anything-new https://psnet.ahrq.gov

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44555/psn-pdf
     October 07, 2015 - Learning without borders: a review of the implementation of medical error reporting in Médecins Sans … Learning without Borders: A Review of the Implementation of Medical Error Reporting in Médecins Sans … https://psnet.ahrq.gov/issue/learning-without-borders-review-implementation-medical-error-reporting- … https://psnet.ahrq.gov/issue/learning-without-borders-review-implementation-medical-error-reporting-medecins-sans … https://psnet.ahrq.gov/issue/learning-without-borders-review-implementation-medical-error-reporting-medecins-sans

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44418/psn-pdf
     September 23, 2015 - Learning from patient safety incidents in incident review meetings: organisational factors and indicators … Learning from patient safety incidents in incident review meetings: Organisational factors and indicators … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-incident-review-meetings-organisational … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-incident-review-meetings-organisational-factors-and … https://psnet.ahrq.gov/issue/learning-patient-safety-incidents-incident-review-meetings-organisational-factors-and

439. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46658/psn-pdf
     April 18, 2018 - Safer healthcare at home: detecting, correcting and learning from incidents involving infusion devices … Safer healthcare at home: detecting, correcting and learning from incidents involving infusion devices … https://psnet.ahrq.gov/issue/safer-healthcare-home-detecting-correcting-and-learning-incidents-involving … https://psnet.ahrq.gov/issue/safer-healthcare-home-detecting-correcting-and-learning-incidents-involving-infusion-devices … https://psnet.ahrq.gov/issue/safer-healthcare-home-detecting-correcting-and-learning-incidents-involving-infusion-devices

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46393/psn-pdf
     September 06, 2017 - The role of South--North partnerships in promoting shared learning and knowledge transfer. … The role of South-North partnerships in promoting shared learning and knowledge transfer. … https://psnet.ahrq.gov/issue/role-south-north-partnerships-promoting-shared-learning-and-knowledge- … https://psnet.ahrq.gov/issue/role-south-north-partnerships-promoting-shared-learning-and-knowledge-transfer … https://psnet.ahrq.gov/issue/role-south-north-partnerships-promoting-shared-learning-and-knowledge-transfer