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psnet.ahrq.gov/node/47457/psn-pdf
January 17, 2019 - This new sentinel
event alert explores how organizations can change their culture to promote reporting … It highlights bright
spots: organizations that use a just culture approach to investigating errors, … The Joint Commission proposes actions for
all organizations to take, including developing incident reporting
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psnet.ahrq.gov/node/34758/psn-pdf
January 29, 2019 - 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
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psnet.ahrq.gov/node/47136/psn-pdf
July 02, 2019 - Adherence to recommended electronic health record
safety practices across eight health care organizations … Adherence to recommended electronic health record safety practices
across eight health care organizations … Researchers
examined the degree to which 8 organizations adhered to the 140 SAFER recommendations and
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psnet.ahrq.gov/issue/where-trust-flourishes-perceptions-clinicians-who-trust-their-organizations-and-are-trusted
March 15, 2023 - Study
Where trust flourishes: perceptions of clinicians who trust their organizations … Where trust flourishes: perceptions of clinicians who trust their organizations and are trusted by their … Where trust flourishes: perceptions of clinicians who trust their organizations and are trusted by their
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psnet.ahrq.gov/issue/race-differences-reported-near-miss-patient-safety-events-health-care-system-high-reliability
March 01, 2023 - Race differences in reported "near miss" patient safety events in health care system high reliability organizations … Race differences in reported "near miss" patient safety events in health care system high reliability organizations … Race differences in reported "near miss" patient safety events in health care system high reliability organizations
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psnet.ahrq.gov/issue/broken-hospital-windows-debating-theory-spreading-disorder-and-its-application-healthcare
October 26, 2022 - Broken hospital windows': debating the theory of spreading disorder and its application to healthcare organizations … Broken hospital windows': debating the theory of spreading disorder and its application to healthcare organizations … Broken hospital windows': debating the theory of spreading disorder and its application to healthcare 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/41222/psn-pdf
May 01, 2016 - Reducing Unnecessary Hospital Readmissions: The Role
of the Patient Safety Organization (PSO). … https://psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization … -
pso
Patient safety organizations (PSO) present a unique opportunity for informing health care safety … The site provides
access to a variety of PSO and other resources to help organizations reduce readmissions … https://psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization-pso
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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/36357/psn-pdf
December 19, 2009 - Error reporting in organizations.
December 19, 2009
Zhao B; Olivera F. … https://psnet.ahrq.gov/issue/error-reporting-organizations
The authors provide a framework for individual … https://psnet.ahrq.gov/issue/error-reporting-organizations
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psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - PSNet also has gone well beyond the published literature, recognizing the role of the news
media, nongovernmental … organizations, and patient advocates in advancing the field. … also helped disseminate the groundbreaking work conducted and funded by AHRQ and other
influential organizations … requires an understanding of
human behavior, the sociology of teams, and the culture of health care organizations … clear that clinicians deserve support, patients deserve
transparency, and both deserve to be part of organizations
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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/45985/psn-pdf
March 29, 2017 - Building a high-reliability organization: one system's
patient safety journey. … March 29, 2017
Building a high-reliability organization: one system's patient safety journey. … https://psnet.ahrq.gov/issue/building-high-reliability-organization-one-systems-patient-safety-journey … High reliability has yet to be achieved in health care organizations. … commentary relates insights from
one health system that sought to implement components of high reliability organizations
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psnet.ahrq.gov/node/37596/psn-pdf
May 01, 2016 - Patient Safety Organization (PSO) Program. … May 1, 2016
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program … Agency for Healthcare Research and Quality (AHRQ) is spearheading the certification of Patient
Safety Organizations … (PSOs)—public or private organizations with expertise in the analysis of patient safety
and hazards … This Web site provides information on the rules governing PSOs and
the requirements for an organization
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psnet.ahrq.gov/issue/approved-no-new-national-patient-safety-goals-only-minor-revisions-2011
January 24, 2007 - Joint Commission on Accreditation of Healthcare Organizations. 2010;30(8):6-7. … Joint Commission on Accreditation of Healthcare Organizations . 2010; 30 :6-7 . … Joint Commission on Accreditation of Healthcare Organizations. 2010;30(8):6-7. … Patient Safety: Supporting a Culture of Continuous Quality Improvement in Hospitals and Other Health Care Organizations
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - To ease
the burden on a strained system, organizations paused elective procedures, reduced in-person … Organizations can move forward and commit to reestablishing patient safety as their purpose
through … Although processes were put in place to address patient safety challenges, many organizations that had … Addressing the Setbacks with Total Systems Safety
In the post-pandemic space, healthcare organizations … Future Directions: Taking Safety Another Step Forward
As organizations level-set and recommit to safety
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psnet.ahrq.gov/node/35728/psn-pdf
February 22, 2006 - Safety climate in health care organizations: a
multidimensional approach. … https://psnet.ahrq.gov/issue/safety-climate-health-care-organizations-multidimensional-approach
The … https://psnet.ahrq.gov/issue/safety-climate-health-care-organizations-multidimensional-approach
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psnet.ahrq.gov/node/41039/psn-pdf
January 04, 2012 - There's a science for that: team development
interventions in organizations. … https://psnet.ahrq.gov/issue/theres-science-team-development-interventions-organizations
This review … https://psnet.ahrq.gov/issue/theres-science-team-development-interventions-organizations
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/865413/psn-pdf
March 27, 2024 - We spoke to them about the risks of cybersecurity to patient safety and how organizations
can prepare … Organizations
should prepare for the loss of communications as well and understand the protocol for … Sarah Mossburg: There are several security frameworks available to healthcare organizations. … types, like small physicians’ practices, small hospitals, and medium and larger organizations. … Depending on their capacity level, the other organizations
may have delays and disruptions as well.
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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