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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - Annual Perspective
Ensuring Patient and Workforce Safety Culture
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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - Ross Koppel, PhD Principal Investigator Study of Hospital Workplace Culture and Medication Errors
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psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
November 13, 2024 - Appendicitis in pregnancy: new information that contradicts long-held clinical beliefs. … March 30, 2022
System planning for modern-day Just Culture to mitigate worker distress
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - Falling Between the Cracks in the Software
Citation Text:
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - Intraoperative cultures were negative for bacteria. … March 9, 2022
Culture change in infection control: applying psychological principles
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - November 26, 2019
Perspectives on Safety
Safety Culture
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psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
October 01, 2017 - Her blood cultures subsequently grew staphylococcus aureus and she was diagnosed with endocarditis
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - Our culture of health, I think, is the most powerful intervention that we have because everything flows … June 30, 2021
Perspectives on Safety
Safety Culture
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psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
August 21, 2024 - The admitting physician ordered blood cultures and prescribed intravenous ceftriaxone as well as oral … the treating physician might offer less information than explained to 'ordinary' patients, due to a belief
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - May 11, 2011
Infection preventionist checklist to improve culture and reduce central
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psnet.ahrq.gov/primer/rapid-response-systems
July 18, 2024 - Rapid Response Systems
Citation Text:
Rapid Response Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Culture and high reliability organizations: the case of the nuclear submarine. J
Manage.
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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - Our culture in health care is very different from those other industries
that have adopted some effective
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psnet.ahrq.gov/node/33760/psn-pdf
February 01, 2014 - We
have this culture such that people are hypersensitive about interrupting someone, but somebody needs
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - I think we have a whole group of physicians who grew up with that belief system and who trained the next … generation in that belief system. … you that I don't know if I did wrong, or I did do wrong, or we don't know what's going on, we have a belief … I don't think it had anything to do with the places as much as the individual cultures of those hospitals … So families have an important role, but if I can be intimidated with what I know and my beliefs about
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psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
January 31, 2024 - harm. 5,6
Violence in healthcare settings impacts patient safety, and guidance is emerging that a culture … tools designed to increase the effectiveness of communication to improve patient safety, especially the culture
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
September 01, 2012 - Later that day, the patient developed fever and chills.
10
11
Case: In Too Long (4)
Blood cultures
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Environment Dynamics:
If the organization functions in a hierarchical model of patient care, move toward a culture
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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - WebM&M Cases
Delayed Recognition of a Positive Blood Culture
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psnet.ahrq.gov/node/846922/psn-pdf
March 29, 2023 - Sustaining This Innovation
To sustain the innovation requires transparency, teamwork, commitment, and a culture