AHRQ Patient Safety Network

The Collection > Learning Organization

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•Diagnostic Errors (3)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (3)

•Medication Safety (13)

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•Surgical Complications (4)

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•Journal Article (55)

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•Special or Theme Issue (3)

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•Epidemiology of Errors and Adverse Events (9)

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Learning Organization

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•Allied Health Services (1)

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Target Audience

•Health Care Providers (34)

•Health Care Executives and Administrators (70)

•Non-Health Care Professionals (54)

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Setting of Care

•Hospitals (39)

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1 - 20 of 84

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STUDY

The need for organizational change in patient safety initiatives.

Anderson JG, Ramanujam R, Hensel D, Anderson MM, Sirio CA. Int J Med Inform. 2006;75:809-817.

COMMENTARY classic

Fixing healthcare from the inside, today.

Spear SJ. Harv Bus Rev. September 2005;83:78-91.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

STUDY

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

STUDY

Does patient-centered design guarantee patient safety?: Using human factors engineering to find a balance between provider and patient needs.

France DJ, Throop P, Walczyk B, et al. J Patient Safety. 2005;1:145-153.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

REVIEW

Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.

COMMENTARY

The competitive imperative of learning.

Edmondson AC. Harv Bus Rev. 2008;86:60-67, 160.

COMMENTARY

What Can the Rest of the Health Care System Learn from the VA’s Quality and Safety Transformation?

Jha AK. AHRQ WebM&M [serial online]. September 2006.

BOOK/REPORT

Resilience Engineering: Concepts and Precepts.

Hollnagel E, Woods DD, Leveson NG, eds. Aldershot, England: Ashgate Publishing; 2006. ISBN: 0754646416.

NEWSPAPER/MAGAZINE ARTICLE

Making it right.

Wright M, Nemeth K. Hosp Health Netw. December 13, 2005.

STUDY

Effects of learning climate and registered nurse staffing on medication errors.

Chang Y, Mark B. Nurs Res. 2011;60:32-39.

STUDY

Managing clinical failure: a complex adaptive system perspective.

Matthews JI, Thomas PT. Int J Health Care Qual Assur. 2007;20:184-194.

STUDY

Bridging the communication gap in the operating room with medical team training.

Awad SS, Fagan SP, Bellows C, et al. Am J Surg. 2005;190:770-774.

COMMENTARY

Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.

McKeon LM, Oswaks JD, Cunningham PD. Clin Nurse Spec. 2006;20:298-304 (CE Test 305-306).

SPECIAL OR THEME ISSUE

Patient Safety Papers.

Baker GE, ed. Healthc Q. 2006;9:1-140.

REVIEW

Learning from samples of one or fewer.

March JG, Sproull LS, Tamuz M. Org Sci. 1991;2:1-13.

REVIEW

Safety and risk management interventions in hospitals: a systematic review of the literature.

Dückers M, Faber M, Cruijsberg J, Grol R, Schoonhoven L, Wensing M. Med Care Res Rev. 2009;66(suppl 6):90S-119S.

NEWSPAPER/MAGAZINE ARTICLE

The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations?

Hofmann PB. Healthc Exec. 2012 May-Jun;27:64,66-67.

COMMENTARY

Is yours a learning organization?

Garvin DA, Edmondson AC, Gino F. Harv Bus Rev. 2008;86:109-116.

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