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61. Adverse events in healthcare: learning from mistakes. | PSNet
    psnet.ahrq.gov/issue/adverse-events-healthcare-learning-mistakes
    February 08, 2017 - Commentary Adverse events in healthcare: learning from mistakes. … Adverse events in healthcare: learning from mistakes. … lack of a standard method to collect and analyze data can hinder progress in determining trends and learning … Adverse events in healthcare: learning from mistakes.

62. Learning mechanisms to limit medication administration errors. | PSNet
    psnet.ahrq.gov/issue/learning-mechanisms-limit-medication-administration-errors
    August 30, 2017 - Study Learning mechanisms to limit medication administration errors. … Learning mechanisms to limit medication administration errors. … Learning mechanisms to limit medication administration errors. … March 1, 2023 Is anybody 'Learning' from deaths? … February 22, 2023 NHS ‘Learning from Deaths’ reports: a qualitative and quantitative

63. Conceptualising learning from resilient performance: a scoping literature review. | PSNet
    psnet.ahrq.gov/issue/conceptualising-learning-resilient-performance-scoping-literature-review
    October 09, 2024 - Conceptualising learning from resilient performance: a scoping literature review. … A cornerstone of resilience engineering is organizational learning . … This scoping review summarizes how learning is discussed in current research. … Descriptions include knowing what has happened; learning from the factual; learning from experience; … Conceptualising learning from resilient performance: a scoping literature review.

64. The role of purple pens in learning to prescribe. | PSNet
    psnet.ahrq.gov/issue/role-purple-pens-learning-prescribe
    June 17, 2020 - Commentary The role of purple pens in learning to prescribe. … The role of purple pens in learning to prescribe. … Participants universally found the initiative to be a learning experience. … The role of purple pens in learning to prescribe. … July 10, 2024 Using learning communities to support adoption of health care innovations

65. Organizational learning starting points and presuppositions: a case study from a hospital’s surgical department. | PSNet
    psnet.ahrq.gov/issue/organizational-learning-starting-points-and-presuppositions-case-study-hospitals-surgical
    September 25, 2024 - Study Organizational learning starting points and presuppositions: a case study from … Organizational learning starting points and presuppositions: a case study from a hospital’s surgical … This qualitative study focuses on the starting points and presuppositions of organizational learning … specific problem) and organizational learning encompassed more formal and intentional practices. … Seeking leverage points for organizational learning.

66. Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review. | PSNet
    psnet.ahrq.gov/issue/informal-learning-error-hospitals-what-do-we-learn-how-do-we-learn-and-how-can-informal
    March 14, 2012 - Review Informal learning from error in hospitals: what do we learn, how do we learn … and how can informal learning be enhanced? … Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning … Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning … March 14, 2012 The relationship between the learning and patient safety climates of clinical

67. The next step in learning from sentinel events in healthcare. | PSNet
    psnet.ahrq.gov/issue/next-step-learning-sentinel-events-healthcare
    June 12, 2024 - Commentary The next step in learning from sentinel events in healthcare. … The next step in learning from sentinel events in healthcare. … To support the development of a national approach to systems learning from sentinel events   (SEs) in … the Netherlands, this study evaluated how SEs are handled and leveraged for learning across eight academic … The next step in learning from sentinel events in healthcare.

68. Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020. | PSNet
    psnet.ahrq.gov/issue/anybody-learning-deaths-sequential-content-and-reflexive-thematic-analysis-national-statutory
    March 01, 2023 - Study Is anybody 'Learning' from deaths? … Is anybody ‘Learning’ from deaths? … In 2017, England’s National Health Service (NHS) implemented the Learning from Deaths program which … Is anybody ‘Learning’ from deaths? … The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020

69. How medical error shapes physicians' perceptions of learning: an exploratory study. | PSNet
    psnet.ahrq.gov/issue/how-medical-error-shapes-physicians-perceptions-learning-exploratory-study
    August 16, 2023 - Study How medical error shapes physicians' perceptions of learning: an exploratory … How Medical Error Shapes Physicians' Perceptions of Learning: An Exploratory Study. … providers experience after an error affect their perceptions of learning. … can facilitate learning from mistakes. … How Medical Error Shapes Physicians' Perceptions of Learning: An Exploratory Study.

70. Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab. | PSNet
    psnet.ahrq.gov/issue/partnership-pathway-diagnostic-excellence-challenges-and-successes-implementing-safer-dx
    April 13, 2022 - Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning … Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning … This qualitative study involving 25 individuals associated with the Safer Dx Learning Lab identified … buy-in and the need for protected time for clinicians to participate in case review and continuous learning … October 28, 2020 Developing health care organizations that pursue learning and exploration

71. The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improvements. | PSNet
    psnet.ahrq.gov/issue/fusion-incident-learning-and-failure-mode-and-effects-analysis-data-driven-patient-safety
    November 17, 2021 - Study The fusion of incident learning and failure mode and effects analysis for data-driven … The fusion of incident learning and failure mode and effects analysis for data-driven patient safety … Assessing risk and learning from adverse events are core components of patient safety improvement. … The fusion of incident learning and failure mode and effects analysis for data-driven patient safety … March 2, 2022 Enabling a learning healthcare system with automated computer protocols

72. Becoming a high-reliability organization through shared learning of safety events | PSNet
    psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events
    February 12, 2020 - Newspaper/Magazine Article Becoming a high-reliability organization through shared learning … of safety events Citation Text: Becoming a high-reliability organization through shared learning … This article discusses a learning model built upon event definition, rapid contributing factor identification … , system-focused communication, and standardized learning to facilitate organizational learning from … Citation Citation Text: Becoming a high-reliability organization through shared learning

73. National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020. | PSNet
    psnet.ahrq.gov/issue/national-statutory-reporting-not-even-ticking-boxes-quality-learning-deaths-reporting-quality
    February 22, 2023 - The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020 … The quality of ‘Learning from Deaths’ reporting in quality accounts within the NHS in England 2017–2020 … The quality of ‘Learning from Deaths’ reporting in quality accounts within the NHS in England 2017–2020 … February 22, 2023 NHS ‘Learning from Deaths’ reports: a qualitative and quantitative … March 2, 2022 Indicators for implementation outcome monitoring of reporting and learning

74. Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. | PSNet
    psnet.ahrq.gov/issue/grand-rounds-methodology-key-considerations-implementing-machine-learning-solutions-quality
    July 26, 2023 - Commentary Grand rounds in methodology: key considerations for implementing machine learning … Grand rounds in methodology: key considerations for implementing machine learning solutions in quality … This article highlights machine learning applications in quality improvement and patient safety (e.g. … , decision support) and practice considerations before deploying machine learning applications (e.g., … February 1, 2023 Positive approaches to safety: learning from what we do well.

75. Systemic safety inequities for people with learning disabilities: a qualitative integrative analysis of the experiences of English health and social care for people with learning disabilities, their families and carers. | PSNet
    psnet.ahrq.gov/issue/systemic-safety-inequities-people-learning-disabilities-qualitative-integrative-analysis
    June 30, 2021 - Study Systemic safety inequities for people with learning disabilities: a qualitative … Systemic safety inequities for people with learning disabilities: a qualitative integrative analysis … of the experiences of English health and social care for people with learning disabilities, their families … Patients with learning disabilities encounter unique patient safety threats . … systematic review of learning tools that could be adapted and used in healthcare.

76. Understanding and learning from organisational failure. | PSNet
    psnet.ahrq.gov/issue/understanding-and-learning-organisational-failure
    April 19, 2011 - Commentary Understanding and learning from organisational failure. … Understanding and learning from organisational failure. Qual Saf Health Care. 2003;12(2):81-2. … Understanding and learning from organisational failure. Qual Saf Health Care. 2003;12(2):81-2. … March 3, 2011 Learning from litigation. … June 22, 2009 Exploring the barriers to learning from crisis: organizational learning

77. The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses. | PSNet
    psnet.ahrq.gov/issue/gift-failure-new-approaches-analyzing-and-learning-events-and-near-misses
    August 07, 2019 - Special or Theme Issue The Gift of Failure: New Approaches to Analyzing and Learning … Citation Text: The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses … August 1, 2014 Organizational Learning from Experience in High-Hazard Industries: Problem … Learning from disasters to improve patient safety. … August 8, 2010 Development of a measure of patient safety event learning responses.

78. Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. | PSNet
    psnet.ahrq.gov/issue/towards-safer-healthcare-qualitative-insights-process-view-organisational-learning-failure
    July 21, 2021 - Towards safer healthcare: qualitative insights from a process view of organisational learning … Towards safer healthcare: qualitative insights from a process view of organisational learning from failure … Findings from these interviews suggest that the primary barriers to active learning stem from social … Towards safer healthcare: qualitative insights from a process view of organisational learning from failure … March 13, 2024 Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive.

79. Learning from errors with the new COVID-19 vaccines. | PSNet
    psnet.ahrq.gov/issue/learning-errors-new-covid-19-vaccines
    October 21, 2021 - Newspaper/Magazine Article Learning from errors with the new COVID-19 vaccines. … Citation Text: Learning from errors with the new COVID-19 vaccines. ISMP Medication Safety Alert! … Learning from error  rests on transparency efforts buttressed by frontline reports. … Linkedin Copy URL Cite Citation Citation Text: Learning … Primers Medication Administration Errors March 12, 2021 Learning

80. Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. | PSNet
    psnet.ahrq.gov/issue/improving-diagnostic-performance-through-feedback-diagnosis-learning-cycle
    December 16, 2020 - Commentary Improving diagnostic performance through feedback: the Diagnosis Learning … Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. … collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning … Improving diagnostic performance through feedback: the Diagnosis Learning Cycle. … A program to provide clinicians with feedback on their diagnostic performance in a learning