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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - Do we have an organization where staff feel comfortable reporting? … Do we have a learning organization where we are thinking about improvement? … If that is not part of this organization, we could put that RCA back on the shelf and not look at it … In our organization, people would call in sick because they did not feel comfortable and did not want … I encourage organizations to use the tools that their organization is ready for.
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - Do we have an organization where staff feel comfortable reporting? … Do we have a learning organization where we are thinking about improvement? … If that is not part of this organization, we could put that RCA back on the shelf and not look at it … In our organization, people would call in sick because they did not feel comfortable and did not want … I encourage organizations to use the tools that their organization is ready for.
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psnet.ahrq.gov/node/37668/psn-pdf
March 11, 2017 - Becoming a High Reliability Organization: Operational
Advice for Hospital Leaders. … https://psnet.ahrq.gov/issue/becoming-high-reliability-organization-operational-advice-hospital-leaders … https://psnet.ahrq.gov/issue/becoming-high-reliability-organization-operational-advice-hospital-leaders
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psnet.ahrq.gov/issue/factors-causing-variation-world-health-organization-surgical-safety-checklist-effectiveness
January 12, 2022 - Review
Factors causing variation in World Health Organization surgical safety checklist … Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid … Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid
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psnet.ahrq.gov/node/35034/psn-pdf
November 05, 2015 - Seven Leadership Leverage Points for Organization-Level
Improvement in Health Care. … https://psnet.ahrq.gov/issue/seven-leadership-leverage-points-organization-level-improvement-health-care … https://psnet.ahrq.gov/issue/seven-leadership-leverage-points-organization-level-improvement-health-care
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - relative acceptability and the
involvement of frontline personnel in identifying safety hazards for the organization … While event
reporting utilization can be a marker of a positive safety culture within an organization … , organizations should
resist the temptation to encourage event reporting without a concrete plan for … safety information when health care providers work with new expert entities known as Patient Safety
Organizations … https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program
http://www.pso.ahrq.gov/common
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psnet.ahrq.gov/node/838257/psn-pdf
October 05, 2022 - The Canadian organization involved applied
Reason’s strategies to work past blame to examine the events … and consider how just culture can be
entrenched organization-wide to improve safety for patients, families … managing-risks-organizational-accidents
https://psnet.ahrq.gov/issue/fostering-just-culture-healthcare-organizations-experiences-practice
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psnet.ahrq.gov/issue/case-birth-and-death-high-reliability-healthcare-organisation
June 18, 2013 - This commentary reviews the characteristics of a high-reliability organization (HRO). … safe HRO and how staff reverted to a standard medical model when advocates of the HRO model left the organization … September 27, 2010
Creating high reliability in health care organizations.
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psnet.ahrq.gov/issue/effectiveness-surgical-safety-checklist-correcting-errors-literature-review-applying-reasons
January 10, 2018 - Organizations including The Joint Commission , the World Health Organization , and the Centers for … February 18, 2017
Postoperative adverse events inconsistently improved by the World Health Organization
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psnet.ahrq.gov/issue/implementing-safety-hotlines-stamford-healths-experience-and-future-opportunities
March 23, 2011 - This commentary describes how one organization implemented a hotline for patients to report concerns … , 2014
Antecedents of willingness to report medical treatment errors in health care organizations … July 10, 2008
House staff team workload and organization effects on patient outcomes
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psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
November 18, 2015 - causes other than pressures related to the timeline: a dispersion of knowledge to silos within the organization … Those who have worked in a health care organization in which a prominent, adverse event has occurred … November 27, 2009
The Limits of Safety: Organizations, Accidents and Nuclear Weapons.
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psnet.ahrq.gov/issue/rise-patient-safety-organizations
September 29, 2017 - Newspaper/Magazine Article
The rise of patient safety organizations. … Citation Text:
The rise of patient safety organizations. Ivill DS, Kearbey AH. New York Law J. … This news feature discusses legal aspects of Patient Safety Organizations ' (PSO) role in data collection … Cite
Citation
Citation Text:
The rise of patient safety organizations
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psnet.ahrq.gov/node/855421/psn-pdf
November 15, 2023 - optimization in older adults: development and
dissemination of VIONE methodology in a high reliability
organization … optimization in older adults: development and dissemination of VIONE methodology in a high reliability
organization … informatics-tools-deprescribing-and-medication-optimization-older-adults-development-and
https://psnet.ahrq.gov/issue/understanding-principles-high-reliability-organizations-through-eyes-vione-clinical-program
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psnet.ahrq.gov/issue/strategies-and-tips-maximizing-failure-mode-and-effect-analysis-your-organization
January 13, 2016 - Report
Strategies and tips for maximizing failure mode and effect analysis in your organization … Citation Text:
Strategies and tips for maximizing failure mode and effect analysis in your organization … Citation
Citation Text:
Strategies and tips for maximizing failure mode and effect analysis in your organization
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psnet.ahrq.gov/node/60906/psn-pdf
August 18, 2021 - August 18, 2021
Geneva, Switzerland: World Health Organization; 2021. ISBN: 9789240032705. … global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-
harm-health-care
The World Health Organization … provides
strategic policy and implementation direction for a wide range of clinical and governmental organizations
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psnet.ahrq.gov/node/39230/psn-pdf
January 13, 2010 - Common formats allow uniform collection and reporting
of patient safety data by patient safety organizations … Common Formats Allow Uniform Collection and Reporting of Patient Safety Data by Patient
Safety Organizations … patient-safety
This article defines common formats and explains their role in the patient safety organization … comments-common-formats-event-reporting-hospital-version-03-beta
https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program
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psnet.ahrq.gov/curated-library/organizational-learning
September 15, 2025 - Library Organization
Custom - This library is organized by custom section header names. … Read More
Becoming a high-reliability organization through shared learning … Kaiser Permanente's performance improvement system, part 4: creating a learning organization … an updated scientific agenda for funding agencies to support LHS to align research with healthcare organization … Newspaper/Magazine Article
Becoming a high-reliability organization through shared
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psnet.ahrq.gov/issue/organization-wide-adoption-computerized-provider-order-entry-systems-study-based-diffusion
December 14, 2022 - Study
Organization-wide adoption of computerized provider order entry systems: a … Organization-wide adoption of computerized provider order entry systems: a study based on diffusion of … Organization-wide adoption of computerized provider order entry systems: a study based on diffusion of
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psnet.ahrq.gov/issue/report-burden-endemic-health-care-associated-infection-worldwide
November 02, 2022 - Geneva, Switzerland: World Health Organization; 2011. ISBN: 9789241501507. … Geneva, Switzerland: World Health Organization; 2011. ISBN: 9789241501507. … Geneva, Switzerland: World Health Organization; 2011. ISBN: 9789241501507. … is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations
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psnet.ahrq.gov/issue/organization-and-representation-patient-safety-data-current-status-and-issues-around
January 21, 2011 - Commentary
Organization and representation of patient safety data: current status … Organization and representation of patient safety data: current status and issues around generalizability … Organization and representation of patient safety data: current status and issues around generalizability