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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47106/psn-pdf
    August 15, 2018 - Imitating incidents: how simulation can improve safety investigation and learning from adverse events … Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From Adverse Events … https://psnet.ahrq.gov/issue/imitating-incidents-how-simulation-can-improve-safety-investigation-and- learning-adverse … strategies to integrate simulation into care routines to optimize cross-functional organizational learning … https://psnet.ahrq.gov/issue/imitating-incidents-how-simulation-can-improve-safety-investigation-and-learning-adverse
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38000/psn-pdf
    August 03, 2009 - The competitive imperative of learning. August 3, 2009 Edmondson A. … The competitive imperative of learning. Harv Bus Rev. 2008;86(7-8):60-7, 160. … https://psnet.ahrq.gov/issue/competitive-imperative-learning This article draws on experience analyzing … team behavior in hospitals to discuss how learning processes can help organizations execute tasks effectively … https://psnet.ahrq.gov/issue/competitive-imperative-learning https://psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46467/psn-pdf
    October 18, 2017 - The Role of Clinical Learning Environments in Preparing New Clinicians to Engage in Patient Safety. … Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical Learning … https://psnet.ahrq.gov/issue/role-clinical-learning-environments-preparing-new-clinicians-engage-patient … - safety Incorporating patient safety in education and learning environments can augment physician … https://psnet.ahrq.gov/issue/role-clinical-learning-environments-preparing-new-clinicians-engage-patient-safety
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47479/psn-pdf
    December 12, 2018 - "Closing the loop": a mixed-methods study about resident learning from outcome feedback after patient … "Closing the loop": a mixed-methods study about resident learning from outcome feedback after patient … https://psnet.ahrq.gov/issue/closing-loop-mixed-methods-study-about-resident-learning-outcome-feedback … after-patient Seeking feedback on patient outcomes after a patient handoff takes place may provide useful learning … identified both a lack of time and inadequate systems for tracking patients as significant barriers to learning
  5. 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
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46844/psn-pdf
    March 07, 2018 - Learning collaboratives: insights and a new taxonomy from AHRQ's two decades of experience. … Learning Collaboratives: Insights And A New Taxonomy From AHRQ's Two Decades Of Experience. … https://psnet.ahrq.gov/issue/learning-collaboratives-insights-and-new-taxonomy-ahrqs-two-decades- experience … Learning collaboratives are multimodal interventions that are often used to implement evidence-based … The authors suggest that efforts to evaluate learning collaboratives or quality improvement interventions
  7. 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
  8. 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.
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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