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421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43970/psn-pdf
     May 19, 2015 - Organisational reporting and learning systems: innovating inside and outside of the box. … Organisational reporting and learning systems: Innovating inside and outside of the box. … https://psnet.ahrq.gov/issue/organisational-reporting-and-learning-systems-innovating-inside-and-outside … This commentary describes the experiences of two projects aimed at learning from error reports, an internal … https://psnet.ahrq.gov/issue/organisational-reporting-and-learning-systems-innovating-inside-and-outside-box

422. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44691/psn-pdf
     December 02, 2015 - Quality and safety in orthopaedics: learning and teaching at the same time: AOA critical issues. … Quality and Safety in Orthopaedics: Learning and Teaching at the Same Time: AOA Critical Issues. … https://psnet.ahrq.gov/issue/quality-and-safety-orthopaedics-learning-and-teaching-same-time-aoa-critical … establishing a culture of safety that promotes error prevention, teamwork, transparency, and continuous learning … https://psnet.ahrq.gov/issue/quality-and-safety-orthopaedics-learning-and-teaching-same-time-aoa-critical-issues

423. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38934/psn-pdf
     June 28, 2011 - Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning … Medication errors: how reliable are the severity ratings reported to the national reporting and learning … psnet.ahrq.gov/issue/medication-errors-how-reliable-are-severity-ratings-reported-national-reporting- and-learning … Assessment of the severity of medication errors reported to the National Reporting and Learning System … psnet.ahrq.gov/issue/medication-errors-how-reliable-are-severity-ratings-reported-national-reporting-and-learning

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42497/psn-pdf
     February 27, 2014 - A prospective study of the link between the ward's learning practices and medication administration … A prospective study of the link between the ward's learning practices and medication administration … https://psnet.ahrq.gov/issue/how-do-we-learn-errors-prospective-study-link-between-wards-learning- practices-and-medication … Supervisory learning, in which senior nurses monitored and provided feedback for junior nurses, was … https://psnet.ahrq.gov/issue/how-do-we-learn-errors-prospective-study-link-between-wards-learning-practices-and-medication

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47080/psn-pdf
     May 02, 2018 - The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations … https://psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many … https://psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many-safety-violations … https://psnet.ahrq.gov/issue/next-generation-doctors-may-be-learning-bad-habits-teaching-hospitals-many-safety-violations … https://psnet.ahrq.gov/issue/role-clinical-learning-environments-preparing-new-clinicians-engage-patient-safety

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46365/psn-pdf
     September 06, 2017 - Learning to overcome hierarchical pressures to achieve safer patient care: an interprofessional simulation … Learning to Overcome Hierarchical Pressures to Achieve Safer Patient Care: An Interprofessional Simulation … https://psnet.ahrq.gov/issue/learning-overcome-hierarchical-pressures-achieve-safer-patient-care- interprofessional … The authors describe the design and planning of the learning experience and report the results of the … https://psnet.ahrq.gov/issue/learning-overcome-hierarchical-pressures-achieve-safer-patient-care-interprofessional

427. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40554/psn-pdf
     June 22, 2011 - Teaching patient safety in simulated learning experiences. … Teaching patient safety in simulated learning experiences. … https://psnet.ahrq.gov/issue/teaching-patient-safety-simulated-learning-experiences This commentary … describes how simulated learning experiences can improve clinical practice and decision- making skills … https://psnet.ahrq.gov/issue/teaching-patient-safety-simulated-learning-experiences

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39409/psn-pdf
     March 31, 2010 - Learning mechanisms to limit medication administration errors. … Learning mechanisms to limit medication administration errors. … https://psnet.ahrq.gov/issue/learning-mechanisms-limit-medication-administration-errors This study evaluated … mechanisms by which hospital wards learned from medication administration errors and the effect these learning … https://psnet.ahrq.gov/issue/learning-mechanisms-limit-medication-administration-errors

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46541/psn-pdf
     January 31, 2018 - The 2017 ACGME common work hour standards: promoting physician learning and professional development … The 2017 ACGME Common Work Hour Standards: Promoting Physician Learning and Professional Development … https://psnet.ahrq.gov/issue/2017-acgme-common-work-hour-standards-promoting-physician-learning-and- … https://psnet.ahrq.gov/issue/2017-acgme-common-work-hour-standards-promoting-physician-learning-and-professional … https://psnet.ahrq.gov/issue/2017-acgme-common-work-hour-standards-promoting-physician-learning-and-professional

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45862/psn-pdf
     February 08, 2017 - Learning, Candour and Accountability. … https://psnet.ahrq.gov/issue/learning-candour-and-accountability-review-way-nhs-trusts-review-and- investigate-deaths … found them to be lacking, particularly in cases involving patients with mental health conditions or learning … consistently across the NHS to improve the timeliness and quality of investigations and ensure system-level learning … https://psnet.ahrq.gov/issue/learning-candour-and-accountability-review-way-nhs-trusts-review-and-investigate-deaths

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47315/psn-pdf
     August 01, 2018 - Chief Learning Officer. July/August 2018;17:22-25. … https://psnet.ahrq.gov/issue/agent-change Organizational learning is an essential element of safety … one hospital leader drew from the success of aviation strategies to design and implement a robust learning … error-management-lessons-aviation https://psnet.ahrq.gov/issue/building-culture-patient-safety-through-simulation-interprofessional-learning-model … https://psnet.ahrq.gov/primer/debriefing-clinical-learning

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39929/psn-pdf
     July 31, 2012 - The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses. … Sci. 2011;49(1):1-106   https://psnet.ahrq.gov/issue/gift-failure-new-approaches-analyzing-and-learning-events-and-near-misses … concepts by event analysis pioneer Bernhard Wilpert can be developed to present undesirable events as learning … https://psnet.ahrq.gov/issue/gift-failure-new-approaches-analyzing-and-learning-events-and-near-misses … https://psnet.ahrq.gov/issue/whats-past-prologue-organizational-learning-serious-patient-injury

433. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34958/psn-pdf
     June 14, 2011 - Patient safety in an interprofessional learning environment. … Patient safety in an interprofessional learning environment. Med Educ. 2005;39(5):512-3. … https://psnet.ahrq.gov/issue/patient-safety-interprofessional-learning-environment The authors discuss … a patient safety–focused, shared learning program developed by the medical and health faculty at the … https://psnet.ahrq.gov/issue/patient-safety-interprofessional-learning-environment https://psnet.ahrq.gov

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40335/psn-pdf
     December 18, 2014 - Assessing teamwork and communication in the authentic patient care learning environment. … Assessing teamwork and communication in the authentic patient care learning environment. … https://psnet.ahrq.gov/issue/assessing-teamwork-and-communication-authentic-patient-care-learning- environment … https://psnet.ahrq.gov/issue/assessing-teamwork-and-communication-authentic-patient-care-learning-environment … https://psnet.ahrq.gov/issue/assessing-teamwork-and-communication-authentic-patient-care-learning-environment

435. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38484/psn-pdf
     March 18, 2009 - Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. … Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. … https://psnet.ahrq.gov/issue/knowledge-based-errors-anesthesia-paired-controlled-trial-learning-and- … https://psnet.ahrq.gov/issue/knowledge-based-errors-anesthesia-paired-controlled-trial-learning-and-retention … https://psnet.ahrq.gov/issue/knowledge-based-errors-anesthesia-paired-controlled-trial-learning-and-retention

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40684/psn-pdf
     August 10, 2011 - Accountability, organisational learning and risks to patient safety in England: conflict or compromise … Accountability, organisational learning and risks to patient safety in England: Conflict or compromise … https://psnet.ahrq.gov/issue/accountability-organisational-learning-and-risks-patient-safety-england-conflict … https://psnet.ahrq.gov/issue/accountability-organisational-learning-and-risks-patient-safety-england-conflict-or … https://psnet.ahrq.gov/issue/accountability-organisational-learning-and-risks-patient-safety-england-conflict-or

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41185/psn-pdf
     March 24, 2012 - Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. … Learning from near misses: from quick fixes to closing off the Swiss- cheese holes. … https://psnet.ahrq.gov/issue/learning-near-misses-quick-fixes-closing-swiss-cheese-holes This study … https://psnet.ahrq.gov/issue/learning-near-misses-quick-fixes-closing-swiss-cheese-holes https://psnet.ahrq.gov … /issue/organizational-learning-health-care-leaders-need-design-structures-and-processes-enhance

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37071/psn-pdf
     September 30, 2011 - Improving patient safety in radiotherapy by learning from near misses, incidents and errors. … Improving patient safety in radiotherapy by learning from near misses, incidents and errors. … https://psnet.ahrq.gov/issue/improving-patient-safety-radiotherapy-learning-near-misses-incidents-and … https://psnet.ahrq.gov/issue/improving-patient-safety-radiotherapy-learning-near-misses-incidents-and-errors … https://psnet.ahrq.gov/issue/improving-patient-safety-radiotherapy-learning-near-misses-incidents-and-errors

439. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43327/psn-pdf
     July 09, 2014 - Interprofessional learning for medication safety. … Interprofessional learning for medication safety. … https://psnet.ahrq.gov/issue/interprofessional-learning-medication-safety This commentary describes … development of a training program that engaged pharmacy, nursing, and medical students in interprofessional learning … https://psnet.ahrq.gov/issue/interprofessional-learning-medication-safety https://psnet.ahrq.gov/issue

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41143/psn-pdf
     March 08, 2017 - Accelerating what works: using qualitative research methods in developing a change package for a learning … Accelerating what works: using qualitative research methods in developing a change package for a learning … psnet.ahrq.gov/issue/accelerating-what-works-using-qualitative-research-methods-developing- change-package-learning … psnet.ahrq.gov/issue/accelerating-what-works-using-qualitative-research-methods-developing-change-package-learning … psnet.ahrq.gov/issue/accelerating-what-works-using-qualitative-research-methods-developing-change-package-learning