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psnet.ahrq.gov/node/45218/psn-pdf
June 15, 2016 - patient-safety-and-quality-improvement-act-2005-hhs-guidance-regarding-
patient-safety-work
Patient Safety Organizations … Despite those expectations, PSOs still have
obligations to report certain situations to external organizations … patient-safety-and-quality-improvement-act-2005-hhs-guidance-regarding-patient-safety-work
https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program
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psnet.ahrq.gov/issue/teaching-smart-people-learn
September 05, 2012 - Argyris, a Harvard Business School professor, theorizes that companies and organizations must learn in … As individuals, they effectively analyze and problem solve within the organization but become defensive … they design and implement their actions and to develop a deeper understanding of their role within the organization … May 25, 2022
Learning in Action: A Guide to Putting the Learning Organization to Work … March 28, 2017
Working Knowledge: How Organizations Manage What They Know.
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - clinical error rates, improve patient satisfaction, and emphasize a wider culture of
safety within an organization … been shown to positively impact healthcare staff perceptions of
teamwork and communication within an organization … TeamSTEPPS 2.0, which included updates for measuring and quantifying the
impact TeamSTEPPS has on an organization … However, there is still
room for more organizations to implement and leverage TeamSTEPPS training to … to revisit, reinforce, and expand training across their organization.
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psnet.ahrq.gov/node/60929/psn-pdf
September 16, 2020 - Action Plan developed by the National Steering Committee for Patient Safety – a group of 27
national organizations … convened by the Institute for Healthcare Improvement – provides direction for health
care leaders and organizations
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psnet.ahrq.gov/issue/escape-fire-designs-future-health-care
May 26, 2010 - , 2005
The Handbook of Patient Safety Compliance: A Practical Guide for Health Care Organizations … August 16, 2016
To Do No Harm: Ensuring Patient Safety in Health Care Organizations. … May 20, 2019
Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge … January 7, 2019
Working Knowledge: How Organizations Manage What They Know.
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psnet.ahrq.gov/node/867523/psn-pdf
January 15, 2025 - how-do-we-know-when-we-have-done-enough-ensuring-sufficient-patient-
notification-efforts
While large-scale adverse events (LSAEs) are rare, healthcare organizations … This article provides an analytic framework for healthcare
organizations to consider in the event of
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - MD, MPP, MPH, is president of The Joint Commission, the preeminent standard setting and accrediting organization … As I thought more about that in context, it became clear that this organization has really been in continuous … This is a private organization that relies on organizations voluntarily subscribing to our service; they … This is a great organization. … Organizations know they have quality problems.
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psnet.ahrq.gov/node/39173/psn-pdf
November 02, 2014 - significant progress has been made in improving patient safety over the past decade, most health
care organizations … In this commentary, leaders of several
leading safety organizations endorse five principles for transforming … hospitals and clinics into high reliability
organizations.
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psnet.ahrq.gov/node/37219/psn-pdf
June 16, 2011 - of hospital safety culture:
development and validation of the patient safety climate
in healthcare organizations … of hospital safety culture: development and
validation of the patient safety climate in healthcare organizations … -
patient-safety
This study describes the development of the Patient Safety Climate in Healthcare Organizations
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psnet.ahrq.gov/node/72722/psn-pdf
February 10, 2021 - knowledge-attitudes-and-expectations-medical-staff-toward-medical-error-
management-policies
Few medical humanitarian organizations … Interviews
with medical and paramedical staff working in international humanitarian organizations expressed
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psnet.ahrq.gov/node/843328/psn-pdf
February 01, 2023 - workers (HCWs) who are involved in serious adverse events may feel traumatized by those
events, and many organizations … Understanding the association may help organizations develop effective
training programs and increase
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psnet.ahrq.gov/node/74094/psn-pdf
November 17, 2021 - https://psnet.ahrq.gov/issue/workplace-violence-prevention-implementing-strategies-safer-healthcare-organizations … https://psnet.ahrq.gov/issue/workplace-violence-prevention-implementing-strategies-safer-healthcare-organizations
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psnet.ahrq.gov/node/47375/psn-pdf
November 02, 2018 - ethical-duty-health-care-systems-address-interfacility-medical-error-discovery
Learning from other organizations … ethical-duty-health-care-systems-address-interfacility-medical-error-discovery
https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors
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psnet.ahrq.gov/node/50922/psn-pdf
February 19, 2020 - organisation-losing-its-memory-patient-safety-alerts-implementation-
monitoring-and-regulation
Health care organizations … organisation-memory-report-expert-group-learning-adverse-events-nhs-chaired-chief-medical
https://psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors
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psnet.ahrq.gov/node/844042/psn-pdf
February 08, 2023 - psnet.ahrq.gov/issue/ladder-based-safety-culture-assessments-inversely-predict-safety-outcomes
High-reliability organizations … culture-cure-assessments-patient-safety-culture-oecd-countries
https://psnet.ahrq.gov/issue/special-issue-resilience-engineering-and-high-reliability-organizations
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psnet.ahrq.gov/node/849592/psn-pdf
May 31, 2023 - Resources Used and Skills Needed
To implement the intervention, organizations need the following:9 … Getting Started with This Innovation
To begin, organizations should ensure completion of training modules … Organizations should integrate the Fall TIPS Program into local quality plans. … To maintain organization wide buy-in,organizations should have processes for consistent reporting
on … Organizations should evaluate real-time issues that may impact program implementation such as
restrictions
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - clinical error rates, improve patient satisfaction, and emphasize a wider culture of safety within an organization … been shown to positively impact healthcare staff perceptions of teamwork and communication within an organization … TeamSTEPPS 2.0, which included updates for measuring and quantifying the impact TeamSTEPPS has on an organization … to revisit, reinforce, and expand training across their organization. … Over time, after the implementation of TeamSTEPPS within a unit or an organization, there are clear links
-
psnet.ahrq.gov/node/846922/psn-pdf
March 29, 2023 - The hospitals improved collaboration with local social
service organizations and step-down care providers … use their economic power and permanency to invest in the local community and partner
with community organizations … Organizations should make efforts to vet and develop relationships with community
partners and hospitals … Adoption Considerations Use by Others (Use By Other Organizations)
Prime has implemented it in at least … 10 of its hospitals and the innovation team reported that four
organizations have reached out with
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - 2005
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-and-quality-improvement-act-2005
https://psnet.ahrq.gov/primer/culture-safety
https://psnet.ahrq.gov/issue/patient-safety-organization-pso-program
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psnet.ahrq.gov/issue/structural-and-organizational-issues-patient-safety-comparison-health-care-other-high-hazard
February 09, 2011 - performs as it does and discusses complementary theories of organizational safety in other high-hazard organizations … two predominant theories of organizational safety, normal accidents theory and high-reliability organization … May 4, 2022
Evidence Brief: Implementation of High Reliability Organization Principles … July 26, 2011
Risk mitigation in large scale systems: lessons from high reliability organizations