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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/33590/psn-pdf
September 15, 2024 - Background
Most health care organizations are still striving to attain high reliability—the ability … Although the concept of leadership has traditionally been used to refer to the top rungs of an organization … it may seem, despite being accountable for the quality and safety of care being provided in
their organizations … Examples of organizations that have transformed their
practices and organizational culture to emphasize … limited evidence regarding specific strategies leadership can use to prevent disruptive behavior,
some organizations
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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - The concept of safety culture originated outside health care, in studies of high reliability organizations … , which are organizations that consistently minimize adverse events despite carrying out intrinsically … High reliability organizations maintain a commitment to safety at all levels, from frontline providers … Studies have documented considerable variation in perceptions of safety culture across organizations … These surveys ask providers to rate the safety culture in their unit and in the organization as a whole
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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/48051/psn-pdf
June 05, 2019 - While health care organizations
are increasingly focused on measuring burnout and implementing targeted … They estimate that the cost for organizations is about
$7600 per physician each year.
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psnet.ahrq.gov/node/50775/psn-pdf
January 01, 2021 - 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
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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
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psnet.ahrq.gov/issue/improving-patient-safety-patient-focused-high-reliability-team-training
January 07, 2011 - Resources From the Same Author(s)
Safeguarding patients: complexity science, high reliability organizations … October 19, 2022
Keeping patients safe in healthcare organizations: a structuration theory … September 12, 2018
The collapse of sensemaking in organizations: the Mann Gulch disaster … April 6, 2011
Safeguarding patients: complexity science, high reliability organizations
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - Over time, after the implementation of TeamSTEPPS within a unit or an organization, there are clear links … 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.
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psnet.ahrq.gov/issue/building-resilient-patient-safety-culture-large-healthcare-organizations-approach
November 03, 2015 - Error reporting and analysis is a key element of a learning organization.
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psnet.ahrq.gov/node/39063/psn-pdf
December 17, 2009 - Improving patient safety requires development of a culture of safety and transformation into a learning
organization—one … and the descriptive nature of most studies, reducing the
generalizability of these studies for other organizations … safety-and-risk-management-interventions-hospitals-systematic-review-literature
https://psnet.ahrq.gov/primer/culture-safety
https://psnet.ahrq.gov/issue/building-learning-organization … https://psnet.ahrq.gov/issue/building-learning-organization
https://psnet.ahrq.gov/primer/reporting-patient-safety-events … https://psnet.ahrq.gov/issue/risk-mitigation-large-scale-systems-lessons-high-reliability-organizations
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psnet.ahrq.gov/node/867849/psn-pdf
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety. PSNet
[internet]. 2025. … commitment to safety describes how organizations in high-risk fields, such as aviation
and nuclear … power, achieve safety and have come to describe a mode of organization called high reliability
organizations … For instance, few organizations reported that high reliable safety
performance was a top priority for … complex realm of care
delivery, HRO may be applied with variability to the detriment of safety.11 Organizations
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psnet.ahrq.gov/node/74253/psn-pdf
January 12, 2022 - Patient Safety Events and the Role of Patient Safety
Organizations During the COVID-19 Pandemic
January … Patient Safety Events and the Role of Patient Safety Organizations
During the COVID-19 Pandemic. … (PSOs) to the Patient Safety
Organization Privacy Protection Center (PSOPPC).2 There is a perception … Authors
Rhonda Dickman, MSN, RN, CPHQ
Patient Safety Organization (PSO) Director
Tennessee Hospital … Clinical Data Analyst
Atrium Health
Charlotte, NC
Danelle Higgins, MHA, BSN, RN
Patient Safety Organization
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psnet.ahrq.gov/node/35851/psn-pdf
December 23, 2016 - December 23, 2016
Organizations USAJC on A of H. … summarizes types of tubing misconnections reported to the Joint Commission on Accreditation of
Healthcare Organizations
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
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 … If we focus on the most important asset in organizations—the people who are delivering care—the other … Interview
In Conversation with Timothy Vogus about High Reliability Organization … February 26, 2025
Perspective
High Reliability Organization
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - I think a lot of
organizations didn't take that step of fixing the workflows first. … They talked to other organizations. … In a lot of organizations they've really underinvested in that training. … MG: Well, it probably depends on how large the organization is. … These
are tough changes for people and organizations to really make happen.
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - In a learning organization, an event of harm creates a zero harm gap that we yearn to close. … And, when we do have an event of harm, the role of the leader is to help the organization pick itself … Then celebrating when it happens and spreading that good news around the organization, spreading the … best practices throughout the organization. … It is rare that we have organizations staffed by leaders that can do that.
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psnet.ahrq.gov/node/865490/psn-pdf
January 01, 2002 - https://psnet.ahrq.gov/issue/safe-operation-social-construct
High reliability organizations (HRO) are … organizations that operate in complex high-hazard domains for
extended periods without serious accidents
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psnet.ahrq.gov/node/44917/psn-pdf
November 30, 2016 - ://psnet.ahrq.gov/issue/canadian-incident-analysis-framework
Performing incident analysis can help organizations … This toolkit provides a framework to help organizations gather insights from staff, patients,
and family
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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Health care organizations struggle with too many
competing demands to make safety the only workplace … Accreditation and awarding organizations come up with neat little checklists to
quantify it for their … First and foremost, this science pushes us to
view the organization as a collection of routines and … Collective mind in organizations: heedful interrelating on flight decks. … The Fifth Discipline: The Art & Practice of the Learning Organization. New York, NY.