Agent of change.

Newspaper/Magazine Article

Agent of change.

August 1, 2018

Gale SF. Chief Learning Officer. July/August 2018;17:22-25.

View more articles from the same authors.

Organizational learning is an essential element of safety culture. This article reports how one hospital leader drew from the success of aviation strategies to design and implement a robust learning program using simulation and debriefing techniques.

Free full text

Related Resources From the Same Author(s)

The Leapfrog Group's CPOE standard and evaluation tool.

July 30, 2008

Fixing a broken healthcare system.

August 3, 2005

Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors.

August 19, 2015

Medication safety technologies: what is and is not working.

July 29, 2009

Looking to the future of patient safety.

August 27, 2014

Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives.

July 1, 2020

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

February 10, 2010

Using Six Sigma to improve patient safety in the perioperative process.

August 28, 2013

Learning how to learn: compliance with patient safety alerts in the NHS.

August 3, 2005

Promoting Patient Safety: An Ethical Basis for Policy Deliberation.

March 6, 2005

The Ethics of Using QI Methods to Improve Health Care Quality and Safety.

August 16, 2006

Patient safety and adverse maternal health outcomes: the missing social inequalities 'lens.'

October 5, 2005

Health IT Patient Safety Supplemental Items for Hospitals.

July 18, 2018

Connectivity to improve patient safety.

February 24, 2010

Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime.

September 7, 2022

During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes.

September 30, 2020

Human Factors and Technology in the ICU.

July 11, 2018

Actions Needed to Address Employee Misconduct Process and Ensure Accountability.

August 15, 2018

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.

September 4, 2019

Critical Deficiencies at the Washington DC VA Medical Center.

March 21, 2018

Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing.

August 9, 2017

The Safety of Maternity Services in England.

August 25, 2021

Distinct newborn identification requirement.

July 11, 2018

Unprofessional Behavior Leads to Complications.

April 1, 2020

A Patient-Safe Future.

November 14, 2018

A crisis within a crisis.

September 15, 2021

Hospitals own up to errors.

September 2, 2009

Surgical 'black box' could reduce errors.

September 10, 2014

Human factors considerations in using personal protective equipment in the COVID-19 pandemic context: a bi-national survey study.

July 1, 2020

The doctor doesn't listen to her. But the media is starting to.

August 22, 2018

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

December 14, 2022

Just Culture and its critical link to patient safety—part 1 and part 2.

July 25, 2012

When the water breaks.

August 3, 2022

Supporting second victims.

February 21, 2018

Fail-safe patient ID matching remains just out of reach.

July 25, 2018

Comparison of quality measures from US hospitals with physician vs nonphysician chief executive officers.

November 2, 2022

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

"Use as directed" can cause confusion for both patients and practitioners.

September 14, 2016

AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01).

March 4, 2015

Safety still compromised by computer weaknesses.

September 7, 2005

Understanding and Improving Diagnostic Safety in Ambulatory Care.

September 6, 2023

The hard work of failure analysis.

September 7, 2005

How to prevent the top 4 medication errors.

October 17, 2018

Community Pharmacy Survey on Patient Safety Culture.

October 24, 2022

How aviation improves medical safety.

August 5, 2015

Health IT Patient Safety Action and Surveillance Plan.

July 17, 2013

Disruptive clinician behavior: a persistent threat to patient safety.

August 9, 2006

We're not your enemy: an appeal from a consumer to re-imagine tort reform.

August 8, 2007

Delivering Quality Health Services: A Global Imperative for Universal Health Coverage.

July 18, 2018

Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices.

August 12, 2020

With scarce access to interpreters, immigrants struggle to understand doctors' orders.

August 29, 2018

Health IT Safe Practices for Closing the Loop.

August 22, 2018

Lax oversight leaves surgery center regulators and patients in the dark.

August 22, 2018

Health IT Safety Center Roadmap.

July 29, 2015

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

September 5, 2012

ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy.

November 18, 2020

Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts?

June 3, 2020

Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.

December 12, 2018

With oral chemotherapy, we simply must do better!

July 30, 2014

Raising the index of suspicion: red flags that represent credible threats to patient safety.

August 8, 2012

AMA meeting: delegates see boosting quality of care as duty.

July 15, 2009

Heparin errors continue despite prior, high-profile, fatal events.

August 6, 2008

Piecing together medication administration.

May 27, 2009

Nursing Home Complaint Investigations.

September 20, 2006

Pump up the volume: tips for increasing error reporting and decreasing patient harm.

September 8, 2021

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

Students have a key role in a culture of safety: analysis of student-associated medication incidents.

August 8, 2018

Survey results: smart pump data analytics pump metrics that should be monitored to improve safety.

July 25, 2018

Incidence of Adverse Events in Indian Health Service Hospitals.

December 23, 2020

More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.

July 30, 2014

Results of our survey on drug storage, stability, compatibility, and beyond use dating.

April 4, 2012

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events.

September 9, 2015

Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.

July 20, 2016

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Chief resident indirect supervision in training safety study: is a chief resident general surgery service safe for patients?

September 1, 2021

Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.

July 11, 2018

Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.

May 16, 2018

NHTSA Fatigue in EMS Project.

March 14, 2018

Safety with nebulized medications requires an interdisciplinary team approach.

March 7, 2018

Investigating hospital supervision: a case study of regulatory inspectors' roles as potential co-creators of resilience.

April 14, 2021

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.

August 15, 2012

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.

January 19, 2022

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

November 29, 2023

Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events.

July 27, 2022

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Physician Burnout.

August 2, 2017

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

August 12, 2020

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Child-specific risk factors and patient safety.

May 11, 2005

Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients.

November 8, 2023

Doctors and dentists still flooding U.S. with opioid prescriptions.

July 29, 2020

Related Resources

Interview

In Conversation with Regina Hoffman about Building Capacity for Patient Safety

July 31, 2023

Perspectives on Safety

Building Capacity for Patient Safety

July 31, 2023

VHA's movement for change: implementing high-reliability principles and practices.

May 31, 2023

Ensuring competency and safety when onboarding newly hired professional staff.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis.

April 5, 2023

Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame.

March 29, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

National patient safety goal to improve health care equity.

February 8, 2023

Survey results from pharmacists provide support to enhance the organizational response to codes.

October 26, 2022

Can hospitals learn about safety from airlines?

September 15, 2021

Towards safer healthcare: qualitative insights from a process view of organisational learning from failure.

August 25, 2021

Achieving zero inequity: lessons learned from patient safety.

May 27, 2021

Learning from safety incidents in high reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.

March 31, 2021

Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths.

March 24, 2021

Transformational improvement in quality care and health systems: the next decade.

November 25, 2020

Real-time debriefing after critical events: exploring the gap between principle and reality.

November 18, 2020

A doctor gave me an inept diagnosis for a neurological problem. I should know: I’m a neurologist.

October 14, 2020

Special Section: Event Analysis and Risk Management.

October 14, 2020

Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments.

October 7, 2020

COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.

September 30, 2020

The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis.

September 9, 2020

How the pandemic defeated America.

August 19, 2020

Nurses' experiences of organizational learning.

August 19, 2020

Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality.

May 13, 2020

Zero harm in health care.

March 18, 2020

Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence.

February 26, 2020

Becoming a high-reliability organization through shared learning of safety events

January 22, 2020

Harnessing the power of medical malpractice data to improve patient care.

January 8, 2020

Simulation-based clinical systems testing for healthcare spaces: from intake through implementation.

August 2, 2019

See More About The Topic

Hospitals

Facility and Group Administrators

Medicine

Epidemiology of Errors and Adverse Events

Learning Organization

Agent of change.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Agent of change.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site