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Grossmann C, Goolsby WA, Olsen L, McGinnis JM; Institute of Medicine and National Academy of Engineering. Washington, DC: The National Academies Press; 2011. ISBN: 9780309120647.
This report builds on earlier work discussing how process and systems engineering practices can help health care organizations improve quality and safety.
Blame: what does it look like?
Duthie EA. Nurs Manage. 2018;49:18-21.
Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care.
Jeffries M, Keers RN, Phipps DL, et al. PLoS One. 2018;13:e0205419.
Measurement and Monitoring of Safety in Canada: CPSI Safety Improvement Project.
Canadian Patient Safety Institute.
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care.
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
A Patient-Safe Future.
Patient Safety Learning: London, UK; September 2018.
Using learning communities to support adoption of health care innovations.
Carpenter C, Hassell S, Mardon R, et al. Jt Comm J Qual Patient Saf. 2018;44:566-573.
Agent of change.
Gale SF. Chief Learning Officer. July/August 2018;17:22-25.
Changing how we think about healthcare improvement.
Braithwaite J. BMJ. 2018;361:k2014.
Incident learning in radiation oncology: a review.
Ford EC, Evans SB. Med Phys. 2018;45:e100-e119.
Using a network organisational architecture to support the development of Learning Healthcare Systems.
Britto MT, Fuller SC, Kaplan HC, et al. BMJ Qual Saf. 2018;27:937-946.
IDEA4PS: the development of a research-oriented learning healthcare system.
Moffatt-Bruce S, Huerta T, Gaughan A, McAlearney AS. Am J Med Qual. 2018;33:420-442.
An organizational learning framework for patient safety.
Edwards MT. Am J Med Qual. 2017;32:148-155.
An organisation without a memory: a qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety.
Sujan M. Reliab Eng Syst Saf. 2015;144:45-52.
Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration.
Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044.
Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012. ISBN: 9780309260732.
Accelerating what works: using qualitative research methods in developing a change package for a learning collaborative.
Sorensen AV, Bernard SL. Jt Comm J Qual Patient Saf. 2012;38:89-95.
Quality improvement for patient safety: project-level versus program-level learning.
Rivard PE, Parker VA, Rosen AK. Health Care Manage Rev. 2013;38:40-50.
Kaiser Permanente's performance improvement system, part 4: creating a learning organization.
Schilling L, Dearing JW, Staley P, Harvey P, Fahey L, Kuruppu F. Jt Comm J Qual Patient Saf. 2011;37:532-543.
The Safe Tables Collaborative: a statewide experience.
Wagner CA, Cecchettini D, Fletcher J. Jt Comm J Qual Patient Saf. 2011;37:206-210.
Strategies for learning from failure.
Edmondson AC. Harv Bus Rev. April 2011;89:48-55.
Effects of learning climate and registered nurse staffing on medication errors.
Chang Y, Mark B. Nurs Res. 2011;60:32-39.
Establishing a global learning community for incident-reporting systems.
Pham JC, Gianci S, Battles J, et al. Qual Saf Health Care. 2010;19:446-451.
The relationship between organizational leadership for safety and learning from patient safety events.
Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.
Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes.
Burnett S, Benn J, Pinto A, Parand A, Iskander S, Vincent C. Qual Saf Health Care. 2010;19:313-317.
Patient Safety Organizations: a new paradigm in quality management and communication systems in healthcare.
Dotan DB. J Clin Eng. 2009;34:142-146.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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