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Search results for "Learning Organization"
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
Patient Safety Learning: London, UK; September 2018.
This paper provides an analysis of the current status of patient safety in the United Kingdom. The report outlines existing challenges and strategies to drive system improvement, including leadership engagement, shared learning, patient safety data optimization, and building on expertise from other high-risk industries.
Watts E, Rayman G. Diabetes UK. London, UK; 2018.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2016.
Learning organizations are capable of addressing problems through information sharing and learning from past experience to facilitate improvement and innovation. Large system failure occurs when such interventions are not disseminated and implemented. This report discusses the need to ensure that lessons learned in military trauma care are acted on and sustained and recommends that this information be translated for the civilian health system as a way to reduce preventable patient harm in trauma care.
Reinertsen JL, Bisognano M, Pugh MD. 2nd ed. Cambridge, MA: Institute for Healthcare Improvement; 2008.
This white paper describes seven leverage points leaders can use to drive organizational change initiatives for safety and quality. The authors apply this theoretical framework to IHI's 100,000 Lives Campaign, provide a self-assessment tool, and draw from their experience since the 2005 edition.