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241. Supplement to Evaluation Highlight No. 13 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight13supp.pdf
     June 01, 2015 - 2015 Supplement to Evaluation Highlight No. 13: How did CHIPRA quality demonstration States employ learning … These States implemented learning collaboratives and subsequently reported quantifiable improvements … This supplement to the Highlight provides an overview of the learning collaboratives in each of the nine … State learning collaboratives had many similarities, but also differed on a number of dimensions summarized … Table 1: Summary of Learning Collaborative Structure and Features in Nine States Other learning collaborative

242. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73090/psn-pdf
     March 31, 2021 - Learning from safety incidents in high reliability organizations: a systematic review of learning tools … Learning from safety incidents in high-reliability organizations: a systematic review of learning tools … - learning-tools High reliability organizations consistently examine and learn from failures. … https://psnet.ahrq.gov/issue/learning-safety-incidents-high-reliability-organizations-systematic-review-learning-tools … https://psnet.ahrq.gov/issue/learning-safety-incidents-high-reliability-organizations-systematic-review-learning-tools

243. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867656/psn-pdf
     February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety. … We spoke with her about learning systems and their impact on patient safety. … we expect to see in learning health systems. … This is a private initiative to come together as a learning network. … Toward a science of learning systems: a research agenda for the high-functioning Learning Health System

244. Supplement to Evaluation Highlight No. 13 | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/supplhighlight13.html
     June 01, 2015 - Supplement to Evaluation Highlight No. 13 How did CHIPRA quality demonstration States employ learning … These States implemented learning collaboratives and subsequently reported quantifiable improvements … This supplement to the Highlight provides an overview of the learning collaboratives in each of the … State learning collaboratives had many similarities, but also differed on a number of dimensions summarized … Table 1: Summary of Learning Collaborative Structure and Features in Nine States State Practices

245. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/861774/psn-pdf
     January 31, 2024 - Grand rounds in methodology: key considerations for implementing machine learning solutions in quality … 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 … https://psnet.ahrq.gov/issue/mitigating-racial-bias-machine-learning

246. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866438/psn-pdf
     August 07, 2024 - Using machine learning or deep learning models in a hospital setting to detect inappropriate prescriptions … Using machine learning or deep learning models in a hospital setting to detect inappropriate prescriptions … https://psnet.ahrq.gov/issue/using-machine-learning-or-deep-learning-models-hospital-setting-detect- … https://psnet.ahrq.gov/issue/using-machine-learning-or-deep-learning-models-hospital-setting-detect-inappropriate … https://psnet.ahrq.gov/issue/using-machine-learning-or-deep-learning-models-hospital-setting-detect-inappropriate

247. Residents' responses to medical error: coping, learning, and change. | PSNet
     psnet.ahrq.gov/issue/residents-responses-medical-error-coping-learning-and-change
     August 03, 2009 - Study Residents' responses to medical error: coping, learning, and change. … Residents' responses to medical error: coping, learning, and change. Acad Med. 2006;81(1):86-93. … Residents' responses to medical error: coping, learning, and change. … February 15, 2011 Teaching but not learning: how medical residency programs handle errors

248. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     December 01, 2017 - 8 Learning From Defects Learning From Defects 9 3 4 2 1 AHRQ Safety Program For Surgery – Implementation … Document these observations in the Learning from Defects tool. 19 LFD Tool Contributing Factors Learning … Learning From Defects 35 AHRQ Safety Program For Surgery – Implementation SAY: When learning from … From Defects process as needed Learning From Defects 43 Tip: Learning From Defects is a continuous … Review the Learning from Defects process.

249. Transforming service delivery to promote quality of care | Agency for Healthcare Research and Quality
     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

250. Testing a Machine Learning Tool for Facilitating Living Systematic Reviews of Chronic Pain Treatments | Effective Health Care (EHC) Program
     effectivehealthcare.ahrq.gov/products/machine-learning-tool/methods-report

251. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867383/psn-pdf
     December 18, 2024 - context of a health-care organisation and failure: the situational impact of failure on organisational learning … This review includes 49 studies that describe post-failure learning or non-learning behavior within … Several factors susceptible to the impact of learning from failure (e.g., workload, communication) can … https://psnet.ahrq.gov/issue/organizational-learning-framework-patient-safety https://psnet.ahrq.gov … /curated-library/organizational-learning

252. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73065/psn-pdf
     March 24, 2021 - Implementing the clinical occurrence reporting and learning system: a double-loop learning incident … Implementing the clinical occurrence reporting and learning system: a double-loop learning incident … - learning-incident Incident reporting systems are a common method for hospitals to detect patient … https://psnet.ahrq.gov/issue/implementing-clinical-occurrence-reporting-and-learning-system-double-loop-learning-incident … https://psnet.ahrq.gov/issue/implementing-clinical-occurrence-reporting-and-learning-system-double-loop-learning-incident

253. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60820/psn-pdf
     August 19, 2020 - Nurses' experiences of organizational learning. … Nurses' experiences of organisational learning: a qualitative descriptive study. … interviews with nurses to explore their experiences with organizational learning. … managers play a central role in organizational learning. … organisational-learning-hospitals-concept-analysis https://psnet.ahrq.gov/issue/relationship-between-organizational-leadership-safety-and-learning-patient-safety-events

254. Structuring feedback and debriefing to achieve mastery learning goals. | PSNet
     psnet.ahrq.gov/issue/structuring-feedback-and-debriefing-achieve-mastery-learning-goals
     September 02, 2020 - Study Structuring feedback and debriefing to achieve mastery learning goals. … Structuring feedback and debriefing to achieve mastery learning goals. … Structuring feedback and debriefing to achieve mastery learning goals.

255. The husband's story: from tragedy to learning and action. | PSNet
     psnet.ahrq.gov/issue/husbands-story-tragedy-learning-and-action
     February 02, 2022 - Commentary The husband's story: from tragedy to learning and action. … The husband's story: from tragedy to learning and action. … The husband's story: from tragedy to learning and action.

256. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48058/psn-pdf
     June 19, 2019 - Organisational learning in hospitals: a concept analysis. … Organisational learning in hospitals: A concept analysis. … This review defines the concept of organizational learning, characteristics of the activity, and the … https://psnet.ahrq.gov/issue/organisational-learning-hospitals-concept-analysis https://psnet.ahrq.gov … /issue/building-learning-organization https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical

257. Psn-Pdf (pdf file)
     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://

258. Psn-Pdf (pdf file)
     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

259. Psn-Pdf (pdf file)
     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

260. Psn-Pdf (pdf file)
     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