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psnet.ahrq.gov/issue/normal-accidents-living-high-risk-technologies
March 06, 2005 - in the health care literature, normal accidents theory is equally prominent in the study of complex organizations … Many health care organizations would meet Perrow's definition of complexity, but only hospitals would … systems, the case studies offer many fascinating insights into the possible failure modes for complex organizations … Citation
Related Resources From the Same Author(s)
The Limits of Safety: Organizations
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Complex Interactions
In high technology organizations, accidents are “normal”
Small errors combine … of adverse events
Example of Highly Reliable Organization
Achieving safety on flight decks of … Collective mind in organizations: heedful interrelating on flight decks. … Some characteristics of one type of high reliability organization. Organ Sci. 1990;1:160-176. … Critical Elements of Safety Culture
Instill core values in members of organization
Those in charge
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psnet.ahrq.gov/node/45697/psn-pdf
August 29, 2018 - Challenges of implementing a communication-and-
resolution program where multiple organizations must … Challenges of Implementing a Communication-and-Resolution
Program Where Multiple Organizations Must … /psnet.ahrq.gov/issue/challenges-implementing-communication-and-resolution-program-where-
multiple-organizations … ://psnet.ahrq.gov/issue/challenges-implementing-communication-and-resolution-program-where-multiple-organizations … ://psnet.ahrq.gov/issue/challenges-implementing-communication-and-resolution-program-where-multiple-organizations
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psnet.ahrq.gov/issue/competitive-imperative-learning
September 25, 2024 - draws on experience analyzing team behavior in hospitals to discuss how learning processes can help organizations … November 18, 2020
Understanding psychological safety in health care and education organizations … 2017
Kaiser Permanente's performance improvement system, part 4: creating a learning organization
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psnet.ahrq.gov/node/867590/psn-pdf
January 22, 2025 - This article describes the efforts of 11 healthcare
organizations' implementation and six-month sustainment … measure-dx-implementing-pathways-discover-and-learn-diagnostic-errors
https://psnet.ahrq.gov/issue/developing-safer-dx-checklist-ten-safety-recommendations-health-care-organizations-address … https://psnet.ahrq.gov/issue/developing-safer-dx-checklist-ten-safety-recommendations-health-care-organizations-address
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psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizations-deal-major-failures
March 13, 2013 - Commentary
Classic
When things go wrong: how health care organizations … When things go wrong: how health care organizations deal with major failures. … When things go wrong: how health care organizations deal with major failures. … 1, 2011
Adoption of order entry with decision support for chronic care by physician organizations
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psnet.ahrq.gov/node/60969/psn-pdf
November 08, 2023 - patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety
Organizations … //psnet.ahrq.gov/issue/network-patient-safety-databases
https://psnet.ahrq.gov/issue/patient-safety-organizations-hospital-participation-value-and-challenges … https://psnet.ahrq.gov/issue/patient-safety-organizations-hospital-participation-value-and-challenges
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psnet.ahrq.gov/node/38215/psn-pdf
November 14, 2011 - Learning from other organizations'
safety errors.
November 14, 2011
Conway JB. … Learning from other organizations' safety errors. Healthcare Executive.
2008;23(6):64, 66-67. … https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors
This brief … article explains step-by-step how health care leadership can learn from failures at other
organizations … https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors
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psnet.ahrq.gov/node/39191/psn-pdf
February 08, 2011 - Leadership in Healthcare Organizations: A Guide to Joint
Commission Leadership Standards. … https://psnet.ahrq.gov/issue/leadership-healthcare-organizations-guide-joint-commission-leadership- … standards
This white paper provides comprehensive information on leadership standards for health care
organizations … https://psnet.ahrq.gov/issue/leadership-healthcare-organizations-guide-joint-commission-leadership-standards … https://psnet.ahrq.gov/issue/leadership-healthcare-organizations-guide-joint-commission-leadership-standards
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psnet.ahrq.gov/node/47954/psn-pdf
August 07, 2019 - Special Issue on Resilience Engineering and High
Reliability Organizations. … https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations … https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations
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psnet.ahrq.gov/node/35267/psn-pdf
April 29, 2018 - High-reliability organizations (HROs): what they know that
we don't (Part II). … https://psnet.ahrq.gov/issue/high-reliability-organizations-hros-what-they-know-we-dont-part-ii
This … article concludes a two-part introduction to the concept of high-reliability organizations (HROs). … https://psnet.ahrq.gov/issue/high-reliability-organizations-hros-what-they-know-we-dont-part-ii
https … ://psnet.ahrq.gov//#highreliabilityorganizations
https://psnet.ahrq.gov/issue/high-reliability-organizations-hros-what-they-know-we-dont-part-i
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psnet.ahrq.gov/node/34898/psn-pdf
April 21, 2011 - Crossing to safety: transforming healthcare organizations
for patient safety. … Crossing to safety: transforming healthcare organizations for patient safety. … https://psnet.ahrq.gov/issue/crossing-safety-transforming-healthcare-organizations-patient-safety
The … authors argue that health care organizations have fallen short of safety goals. … https://psnet.ahrq.gov/issue/crossing-safety-transforming-healthcare-organizations-patient-safety
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psnet.ahrq.gov/node/40429/psn-pdf
July 22, 2011 - Keeping patients safe in healthcare organizations: a
structuration theory of safety culture. … Keeping patients safe in healthcare organizations: a
structuration theory of safety culture. … https://psnet.ahrq.gov/issue/keeping-patients-safe-healthcare-organizations-structuration-theory-safety … https://psnet.ahrq.gov/issue/keeping-patients-safe-healthcare-organizations-structuration-theory-safety-culture … https://psnet.ahrq.gov/issue/keeping-patients-safe-healthcare-organizations-structuration-theory-safety-culture
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psnet.ahrq.gov/node/42419/psn-pdf
July 17, 2013 - of Medicine report, Health IT and Patient Safety, the plan includes
specific action items for HHS organizations … Responsibilities will be shared across a number of HHS organizations: the Office of the National
Coordinator … clinicians to report health IT–related incidents and
hazards, encouraging reporting to Patient Safety Organizations … health-it-and-patient-safety-building-safer-systems-better-care
https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program
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psnet.ahrq.gov/node/41602/psn-pdf
August 15, 2012 - How Can Health Care Organizations Become More Health
Literate?: Workshop Summary. … https://psnet.ahrq.gov/issue/how-can-health-care-organizations-become-more-health-literate-workshop- … summary
This report details the results of a workshop on health literacy in health care organizations … https://psnet.ahrq.gov/issue/how-can-health-care-organizations-become-more-health-literate-workshop-summary … https://psnet.ahrq.gov/issue/how-can-health-care-organizations-become-more-health-literate-workshop-summary
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psnet.ahrq.gov/node/72836/psn-pdf
January 26, 2021 - has demonstrated that patients who are
more actively engaged in their care have better outcomes.[3]
Organizations … Other organizations, notably PFCCPartners, provide support to institutions seeking to
establish patient … However, for organizations that are experienced with PFE or have advanced PFE
programs, PFE measurement … Not only can the
development of PFE outcome measures help organizations systematically track the impact … Quality Improvement Organizations. Accessed February 1, 2021.
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psnet.ahrq.gov/node/865697/psn-pdf
April 24, 2024 - Sarah Mossburg: Together with the American Association of Critical-Care Nurses, American Organization … Sarah Mossburg: What solutions are healthcare organizations using to address the staffing challenges … Some organizations also offer housing for aspiring nurses as they attend school and are partnering with … Some
organizations are setting up programs where nurses “float” to different hospitals within a system … If we focus on the most important asset in organizations—the people who are delivering care—the other
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psnet.ahrq.gov/node/73314/psn-pdf
May 26, 2021 - (PE for PS) for healthcare
managers to assess patient engagement for patient safety
in healthcare organizations … (PE for PS) for healthcare
managers to assess patient engagement for patient safety in healthcare organizations … The tool contains four sections: (1) describing the healthcare organization; (2) gathering general
information
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psnet.ahrq.gov/node/855057/psn-pdf
October 31, 2023 - psnet.ahrq.gov//#5
standards in 2022 to guide hospitals in defining workplace violence and implementing organization-wide … for patients and healthcare workers, workplace violence of all types negatively
impacts healthcare organizations … addition to addressing barriers to reporting, healthcare leaders
should make it clear that it is the organization … It is critical for organizations to establish and enforce a zero-tolerance
policy towards bullying, … To achieve improved workforce safety, organizations should start with a systems approach, which includes
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psnet.ahrq.gov/node/42056/psn-pdf
January 01, 2014 - Antecedents of willingness to report medical treatment
errors in health care organizations: a multilevel … Antecedents of willingness to report medical treatment errors in health care
organizations: a multilevel … https://psnet.ahrq.gov/issue/antecedents-willingness-report-medical-treatment-errors-health-care-
organizations-multilevel … https://psnet.ahrq.gov/issue/antecedents-willingness-report-medical-treatment-errors-health-care-organizations-multilevel … https://psnet.ahrq.gov/issue/antecedents-willingness-report-medical-treatment-errors-health-care-organizations-multilevel