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psnet.ahrq.gov/node/849324/psn-pdf
May 24, 2023 - Learning from errors and resilience.
May 24, 2023
Arnal-Velasco D, Heras-Hernando V. … Learning from errors and resilience. … https://psnet.ahrq.gov/issue/learning-errors-and-resilience
The Safety II framework and organizational … The authors suggest learning from
errors or what goes right should be reframed simply as learning. … https://psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
https://
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www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/finalsummary/finalsummary3.html
September 01, 2015 - collaboratives, including group instruction with peer-to-peer learning opportunities, in-person meetings … , and web-based learning sessions. … Although learning collaboratives can help build providers’ capacity, not all practices want to improve … Oregon, West Virginia , and Alaska used learning collaboratives, one-on-one practice facilitation, … Demonstration staff used in-person learning sessions, conference calls, and one-on-one support to help
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psnet.ahrq.gov/node/836860/psn-pdf
April 06, 2022 - Learning environments, reliability enhancing work
practices, employee engagement, and safety climate … Learning environments, reliability enhancing work practices,
employee engagement, and safety climate … Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture … The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the
association … Learning
environments with higher average LEHR scores were associated with higher employee engagement
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psnet.ahrq.gov/node/837665/psn-pdf
July 13, 2022 - Evaluating a patient safety learning laboratory to create
an interdisciplinary ecosystem for health … Evaluating a patient safety learning laboratory to create an
interdisciplinary ecosystem for health … https://psnet.ahrq.gov/issue/evaluating-patient-safety-learning-laboratory-create-interdisciplinary- … This study reports on how a learning ecosystem supported the success of three distinct
PSLLs. … https://psnet.ahrq.gov/issue/overview-patient-safety-learning-laboratory-projects
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/48187/psn-pdf
August 21, 2019 - How medical error shapes physicians' perceptions of
learning: an exploratory study. … How Medical Error Shapes Physicians' Perceptions of
Learning: An Exploratory Study. … experience after an error affect their perceptions of learning. … Both cultural and individual factors facilitated and deterred learning from
these experiences. … can facilitate learning from
mistakes.
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psnet.ahrq.gov/node/867042/psn-pdf
October 30, 2024 - The foundational science of learning health systems. … The foundational science of learning health systems. … https://psnet.ahrq.gov/issue/foundational-science-learning-health-systems
Learning health systems (LHS … https://psnet.ahrq.gov/issue/foundational-science-learning-health-systems
https://psnet.ahrq.gov/glossary … /issue/kaiser-permanentes-performance-improvement-system-part-4-creating-learning-organization
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psnet.ahrq.gov/node/866195/psn-pdf
June 26, 2024 - https://psnet.ahrq.gov/issue/exaggerated-benefits-failure
Failure can be considered a learning opportunity … This article describes seven studies concerning people’s estimates of learning from previous
failures … https://psnet.ahrq.gov/issue/exaggerated-benefits-failure
https://psnet.ahrq.gov/issue/strategies-learning-failure … https://psnet.ahrq.gov/issue/using-trainee-failures-enhance-learning-qualitative-study-pediatric-hospitalists-allowing … https://psnet.ahrq.gov/issue/giving-learning-failures-examination-learning-ones-own-failures-context-heart-surgeons
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psnet.ahrq.gov/node/836748/psn-pdf
March 16, 2022 - Analysis of the interprofessional clinical learning
environment for quality improvement and patient … Analysis of the interprofessional clinical learning environment for
quality improvement and patient … https://psnet.ahrq.gov/issue/analysis-interprofessional-clinical-learning-environment-quality-improvement … Benefits (e.g., learning about other professions), facilitators, and barriers to resident
involvement … and a positive clinical learning environment were identified.
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psnet.ahrq.gov/node/48182/psn-pdf
August 21, 2019 - Organizational learning in hospitals: a realist review. … Organizational learning in hospitals: A realist review. … that affect it, how such learning occurs, and
improvements implemented as a result. … https://psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
https://psnet.ahrq.gov/ … /issue/water-cooler-learning-knowledge-sharing-clinical-backstage-and-its-contribution-patient
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psnet.ahrq.gov/node/764404/psn-pdf
March 02, 2022 - 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 … 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 … -
analysis
Patients with learning disabilities encounter unique patient safety threats.
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psnet.ahrq.gov/node/860386/psn-pdf
January 10, 2024 - Conceptualising learning from resilient performance: a
scoping literature review. … 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;
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psnet.ahrq.gov/node/73658/psn-pdf
September 01, 2021 - Predicting self-intercepted medication ordering errors
using machine learning. … Predicting self-intercepted medication ordering errors using machine
learning. … https://psnet.ahrq.gov/issue/predicting-self-intercepted-medication-ordering-errors-using-machine-learning … https://psnet.ahrq.gov/issue/learning-errors-analysis-medication-order-voiding-cpoe-systems
https:// … psnet.ahrq.gov/issue/machine-learning-medicine
https://psnet.ahrq.gov/issue/machine-learning-based-clinical-decision-support-system-identify-prescriptions-high-risk
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psnet.ahrq.gov/node/60872/psn-pdf
September 02, 2020 - How incident reporting systems can stimulate social and
participative learning: a mixed-methods study … How incident reporting systems can stimulate social and participative
learning: a mixed-methods study … https://psnet.ahrq.gov/issue/how-incident-reporting-systems-can-stimulate-social-and-participative-learning … this study evaluated how incident reporting systems in the
Netherlands contribute to organizational learning … ; (4) local learning, and; (5) recommendations that improve care quality and safety.
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psnet.ahrq.gov/node/74116/psn-pdf
November 24, 2021 - NCICLE Pathways to Excellence: Expectations for an
Optimal Clinical Learning Environment to Achieve … November 24, 2021
Chicago, IL: National Collaborative for Improving the Clinical Learning Environment … This report discusses characteristics of an environment that nurtures learning across disciplines in … https://psnet.ahrq.gov/issue/best-care-lower-cost-path-continuously-learning-health-care-america
https … ://psnet.ahrq.gov/issue/clinical-learning-environment-review-cler-program
https://psnet.ahrq.gov/issue
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psnet.ahrq.gov/node/73630/psn-pdf
August 25, 2021 - Towards safer healthcare: qualitative insights from a
process view of organisational learning from failure … Towards safer healthcare: qualitative insights from a process view of
organisational learning from failure … in high- and low-performing hospitals to
better understand the barriers to effective organizational learning … Findings from these
interviews suggest that the primary barriers to active learning stem from social … https://psnet.ahrq.gov/issue/blaming-learning-re-framing-organisational-learning-adverse-incidents
https
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psnet.ahrq.gov/node/48003/psn-pdf
June 26, 2019 - Comparison of the accuracy of human readers versus
machine-learning algorithms for pigmented skin lesion … Comparison of the accuracy of human readers versus machine-
learning algorithms for pigmented skin lesion … Machine learning may have the potential to improve clinical decision-making and diagnosis. … In this study,
machine-learning algorithms generally performed better than human experts in accurately … https://psnet.ahrq.gov/issue/machine-learning-medicine
https://psnet.ahrq.gov/issue/predicting-future-big-data-machine-learning-and-clinical-medicine
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www.ahrq.gov/hai/cusp/modules/identify/identify.html
December 01, 2012 - Learning Objectives
Slide 4. The Relationship Between CUSP and Sensemaking 1,2,3
Slide 5. … Learning From Defects and Sensemaking
Slide 18. Learning From Defects Overview
Slide 19. … Summary of Sensemaking and Learning From Defects
Slide 34. References
Slide 35. … and Learning from Defects share several common themes. … Sensemaking and Learning from Defects are ongoing processes.
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psnet.ahrq.gov/node/865348/psn-pdf
January 01, 2023 - Learning Health Systems
January 1, 2023
Agency for Health Research and Quality. … https://psnet.ahrq.gov/issue/learning-health-systems
The learning health system model centers on the … website shares projects,
articles, and implementation examples to enhance adoption of the organizational learning … https://psnet.ahrq.gov/issue/learning-health-systems
https://psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance … https://psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety
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psnet.ahrq.gov/node/73444/psn-pdf
June 30, 2021 - Exploring patient safety outcomes for people with
learning disabilities in acute hospital settings: … Exploring patient safety outcomes for people with learning
disabilities in acute hospital settings: … https://psnet.ahrq.gov/issue/exploring-patient-safety-outcomes-people-learning-disabilities-acute-hospital … -
settings
Prior research found that patients with learning disabilities (e.g., autism, attention deficit … Findings suggest that individuals with learning disabilities experience poorer patient outcomes but
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psnet.ahrq.gov/node/851061/psn-pdf
June 28, 2023 - Learning from experience: a qualitative study of
surgeons' perspectives on reporting and dealing with … Learning from experience: a qualitative study of surgeons’
perspectives on reporting and dealing with … https://psnet.ahrq.gov/issue/learning-experience-qualitative-study-surgeons-perspectives-reporting-and … -
dealing-serious
Reporting and learning from adverse events are core components of patient safety. … /prevention-better-cure-learning-adverse-events-healthcare