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psnet.ahrq.gov/issue/organisational-readiness-exploring-preconditions-success-organisation-wide-patient-safety
February 01, 2011 - Implementation of large-scale safety improvement programs requires learning organizations —organizations … This qualitative study evaluated the readiness of each organization to undertake this initiative, and … January 6, 2010
The Limits of Safety: Organizations, Accidents and Nuclear Weapons. … Administrators
Safety Scientists
Policy Makers
Quality Improvement Strategies
Learning Organization
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - addition to addressing barriers to reporting, healthcare leaders should make it clear that it is the organization … My work largely focuses on the organization, delivery, and financing of care, and how the healthcare … When you’re working in an organization where there are clear power differentials and stressful conditions … an organization is important. … It is one of those things that can tip people over in their decision to leave a unit, leave an organization
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psnet.ahrq.gov/issue/quality-improvement-patient-safety-project-level-versus-program-level-learning
April 01, 2010 - success of quality improvement programs and found that program-level learning (i.e., becoming a learning organization … : cultivating organization wide quality improvement and health care professional engagement. … All of us will fail and make mistakes, but how can they benefit us and our organizations? … Learning from other organizations' safety errors. … Health Care Executives and Administrators
General Internal Medicine
Hospital Medicine
Learning Organization
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psnet.ahrq.gov/issue/perspective-culture-respect-part-1-and-part-2
October 04, 2006 - Lucian Leape issues a challenge to health care organizations to eliminate disruptive behavior, identifying … The second part discusses the role a culture of respect plays in developing high-reliability organizations … and identifies specific strategies organizations can use to address disruptive and disrespectful behaviors … The chilling effect of disrespectful behavior, and how an organization responded, is discussed in an
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - There's literature and a lot of analysis of high reliability organizations—organizations that deal with … at every level knows they have a critical role to play in safety in that organization. … Well, no high reliability organization on the planet has an entirely blame-free culture. … organization and makes the accreditation work much harder, I would think. … That's where high reliability organizations are.
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psnet.ahrq.gov/node/73148/psn-pdf
April 14, 2021 - 10 Leadership mindsets for high reliability organizations. … https://psnet.ahrq.gov/issue/10-leadership-mindsets-high-reliability-organizations-how-empower-caregivers … https://psnet.ahrq.gov/issue/10-leadership-mindsets-high-reliability-organizations-how-empower-caregivers-and-engage … https://psnet.ahrq.gov/issue/10-leadership-mindsets-high-reliability-organizations-how-empower-caregivers-and-engage
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psnet.ahrq.gov/issue/role-leaders-health-care-organizations-patient-safety
September 27, 2010 - Commentary
The role for leaders of health care organizations in patient safety. … The role for leaders of health care organizations in patient safety. … The role for leaders of health care organizations in patient safety.
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Many organizations
depend heavily on IT for daily operations. … the user clicks the link, malware is installed on
their work computer and can spread to the whole organization … , more than half (54%) said their organizations experienced
ransomware attacks in 2023, and 59% said … ensure no duplicate prescriptions to patients exist.10
Finally, it is critically important for the organization … These steps can help the organization prevent, prepare
for, respond to, and recover from cyberattacks
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psnet.ahrq.gov/issue/content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-handovers-and
December 14, 2022 - safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations … safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations … safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations … Quality
April 26, 2023
Learning from safety incidents in high reliability organizations
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psnet.ahrq.gov/issue/chpso-2019-annual-report
March 20, 2024 - California Hospital Patient Safety Organization: Sacramento, CA; 2024. … Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their 490 … California Hospital Patient Safety Organization: Sacramento, CA; 2024. … March 20, 2024
Factors causing variation in World Health Organization surgical safety … November 23, 2016
How PSOs Help Health Care Organizations Improve Patient Safety Culture
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psnet.ahrq.gov/issue/sounding-alarm-nurses-organizations-work-address-alarm-fatigue
July 19, 2017 - Nurses, organizations work to address alarm fatigue.
Citation Text:
Trossman S. … Nurses, organizations work to address alarm fatigue. Am Nurs. 2013;45(5):1, 6-7. … Nurses, organizations work to address alarm fatigue. Am Nurs. 2013;45(5):1, 6-7.
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psnet.ahrq.gov/primer/disclosure-errors
September 15, 2024 - explanation as to why the error occurred How the error's effects will be minimized Steps the physician (and organization … This may also require changes in how organizations approach error disclosure. … Research and Quality has developed the Communication and Optimal Resolution (CANDOR) toolkit to help organizations … Current Context Disclosure of errors and adverse events is now endorsed by a broad array of organizations … It also calls for health care organizations to create an environment conducive to disclosure by integrating
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psnet.ahrq.gov/patient-safety-101
March 26, 2025 - UC Davis PSNet Editorial Team |
September 15, 2024
High-reliability organizations … Such organizations establish a culture of safety by maintaining a commitment to safety at all levels, … Hazards
UC Davis PSNet Editorial Team |
September 15, 2024
Health care organizations … UC Davis PSNet Editorial Team |
September 15, 2024
High reliability organizations … are organizations that operate in complex, high-hazard domains for extended periods without serious
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psnet.ahrq.gov/node/867382/psn-pdf
December 18, 2024 - pharmacists-perceptions-error-reporting-systems
Healthcare staff are frequently required to report errors and adverse events to their organization … In this study, community pharmacists in Canada share their experiences reporting to
regulatory organizations … authors suggest that a switch from a compliance-based culture to a just culture, where
workers and organizations
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psnet.ahrq.gov/node/867383/psn-pdf
December 18, 2024 - issue/interactions-between-context-health-care-organisation-and-failure-situational-
impact-failure
Organizations … includes 49 studies that describe post-failure learning or non-learning behavior within healthcare
organizations … interactions-between-context-health-care-organisation-and-failure-situational-impact-failure
https://psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition
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psnet.ahrq.gov/node/38808/psn-pdf
January 01, 2013 - Patient Safety Organizations: a new paradigm in quality
management and communication systems in healthcare … Patient safety organizations. J Clin Engineer. 2013;34(3):142-146. … https://psnet.ahrq.gov/issue/patient-safety-organizations-new-paradigm-quality-management-and-
communication-systems … This commentary discusses patient safety organizations as learning organizations—groups that are able … https://psnet.ahrq.gov/issue/patient-safety-organizations-new-paradigm-quality-management-and-communication-systems
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
March 29, 2023 - This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations … law July 29, 2005, provides legal protection of information voluntarily reported to patient safety organizations … Patient Safety Databases Chartbook, 2019
February 5, 2020
How PSOs Help Health Care Organizations
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psnet.ahrq.gov/node/34951/psn-pdf
February 28, 2011 - psnet.ahrq.gov/issue/ambiguity-and-workarounds-contributors-medical-error
This commentary discusses the role organizations … The
authors contrast characteristics of error-prone organizations with high-performing ones and provide … specific
illustrations of how each type of organization designs and executes work, responds to problems … The authors suggest that health
care organizations should not strive to become factories of repetition
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psnet.ahrq.gov/node/72845/psn-pdf
March 17, 2021 - toward-development-perfect-medical-team-critical-components-adaptation
High reliability remains an elusive goal for health care organizations … outlines practical tools and educational strategies that
can be leveraged by a variety of healthcare organizations … https://psnet.ahrq.gov/primer/high-reliability
https://psnet.ahrq.gov/issue/becoming-high-reliability-organization
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - Can you share
more about the background of the organization and its mission? … We saw the work of patient and family advisory groups grind to a halt in many
organizations, whereas … Some of the characteristics of these organizations send important signals for us to emulate. … What are your thoughts on
how organizations can do so? … Sarah Mossburg: How can organizations use the National Action Plan in their improvement efforts?