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2601. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
      April 21, 2008 - each of the four hospitals were asked to read and concur with the principles included in the “just culture … Reduced patient falls • To promote a culture of safety by encouraging reporting of near-miss falls … based on findings of root cause analyses and sensemaking sessions, enhanced by fostering a just culture … Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability … Patient safety and the “just culture”: A primer for health care executives.

2602. Acute Care Learning From Defects
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
      November 01, 2019 - vancomycin and piperacillin/tazobactam On day 2, he undergoes ERCP and the stone is removed Blood cultures … Have I ordered appropriate cultures before starting antibiotics? … daily briefing about antibiotic regimen with team Institutional factors are related to institution culture … revealed E. coli Develop guidelines for intra-abdominal infections that discuss culture-directed therapy … and feedback for patients on vancomycin Develop vancomycin auto-stops Educate nurses about reviewing culture

2603. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
      January 01, 2024 - Culture, Workflow, and Work System Issues ........................................................... … , Workflow, and Work System Issues Culture: Behavioral Norms Work System Work System: Process Breakdowns … Culture: Behavioral Norms Behavioral norms in the workplace may affect diagnostic safety. … to how culture, behavior, and work system influence diagnostic safety were limited. … /error + culture barriers identified by staff diagnostic safety/error + work system diagnostic safety

2604. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
      April 20, 2004 - where the “two-challenge rule” is practiced— is essential to the growth of an institutional safety culture … : “Designing systems for safety requires specific, clear, and consistent efforts to develop a work culture … It is also necessary for organizational leadership to promote and endorse a culture of support during

2605. Building an Ambulatory Patient Safety Learning Laboratory for Diverse Populations (ASCENT) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/resources/learning-lab/building-ambulatory-long-desc.html
      April 01, 2021 - The ASCENT Lab developed, piloted, and implemented a needs-driven technical and culture-based solution

2606. Implementing Team Approaches for Improving Diabetes Care in Health Centers | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/delivery-initiative/rodriguez/index.html
      December 01, 2020 - Implementing Team Approaches for Improving Diabetes Care in Health Centers Slide Presentation by Hector P. Rodriguez Text version of a slide presentation made by Hector P. Rodriguez, PhD, MPH. Sign up: Quality Measure Tools Email updates Slide 1 Implementing Team Approaches for Improving Diabetes Ca…

2607. Examples of Patient Harm Related to Invasive Devices | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/phys-championsgd/section3.html
      October 01, 2015 - His blood cultures grew methicillin- resistant Staphylococcus aureus (MRSA). … Blood and urine cultures grew Escherichia coli . … Blood cultures grew Staphylococcus aureus , and the catheter tip grew the same organism. … The patient’s bacteremia persisted, and his repeat blood cultures continued to be positive for more than … His sputum culture grew Pseudomonas aeruginosa .

2608. Facilitator-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module5/facilitator-notes.docx
      March 01, 2017 - long-term facilities · Explain the importance of engaging residents and family members to improve the culture … listen to and honor resident perspectives and choices, resident and family makeup, knowledge, values, beliefs … , and religious and cultural background. … The culture at a person-centered facility promotes the philosophy that each person has the opportunity … in identifying resident and family advisers should consider asking advisers who represent different cultures

2609. Variation in the Implementation of California’s Full-Service Partnerships for Persons With Serious Mental Illness (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/system/delivery-system-initiative/gilmerstudysnapshot/gilmerstudysnapshot.pdf
      April 01, 2015 - consider, such as placing a singular focus on client needs, hiring staff whose personal values and beliefs … Critical importance of program director: The program director plays a significant role in creating a culture … f Internal culture, staffing, and protocols: High-fidelity programs describe clients as “underserved … They also tend to hire staff whose personal values and beliefs align with this philosophy (or support

2610. Variation in the Implementation of California’s Full-Service Partnerships for Persons With Serious Mental Illness (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/gilmerstudysnapshot.pdf
      April 01, 2015 - consider, such as placing a singular focus on client needs, hiring staff whose personal values and beliefs … Critical importance of program director: The program director plays a significant role in creating a culture … f Internal culture, staffing, and protocols: High-fidelity programs describe clients as “underserved … They also tend to hire staff whose personal values and beliefs align with this philosophy (or support

2611. 5 Tk2 P2T8-Sample Antibiogram Phase 2 (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P2T8-Sample_Antibiogram_Phase_2.doc
      May 01, 2014 - : Of XXX cultures used to make the antibiograms, XX% were urine cultures, YY% were wound cultures, and … Z% were sputum cultures. … · The leading organisms for positive urine cultures were: · E. coli: XX% of urine cultures · Enterococcus … Urinary tract infections (UTIs) from gram-negative organisms · XX% of positive urine cultures were due … Gram positives · XX of XX (XX%) Staph. aureus cultures were MRSA.

2612. Cholecystitis and Cholangitis (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/biliary-tract-one-page.docx
      November 01, 2019 - antibiotics · Microbiology: Escherichia coli, Klebsiella pneumoniae, Enterococcus species · Blood cultures … should be obtained in all patients with cholangitis · Blood cultures should be obtained in patients … with cholecystitis that have concomitant sepsis · Bile cultures should be obtained if the biliary tree … P. aeruginosa, and anaerobes; consider coverage for Enterococcus species · Review any prior biliary cultures … here] · [Place local recommendations here] · Narrowing and oral therapy · Narrow based on available culture

2613. Decision Making and Readiness for Implementation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/introduction/decision-making.pdf
      March 01, 2022 - clinical trials and adoption after definitive trials must be determined based upon local needs and culture … Choose a 1-year period and count the number of unique patients who have a positive blood culture from … Use your current processes for identifying MRSA carriers using reported history, prior culture result … The order of approaching these key stakeholders will depend on the culture, standard processes, and … cultures, and history of MRSA to target those with devices

2614. 041-Pros-Cons-Mrsa-Surveillance-One-Pager (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/041-pros-cons-mrsa-surveillance-one-pager.docx
      October 01, 2024 - Active Surveillance1 Involves collecting cultures at admission and/or during hospital stay Advantages … additional resources, including increased supplies and staff time to collect and process surveillance cultures … Passive Surveillance1 Involves monitoring the results of clinical cultures that grow MRSA Passive … surveillance methods: · Monitor results of all clinical cultures from symptomatic patients to document … and analyze the cultures that grow MRSA · Use laboratory-identified (LabID) MRSA bacteremia surveillance

2615. Urinary Tract Infections
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/sepsis-slides.pptx
      November 01, 2019 - 7 AHRQ Safety Program for Improving Antibiotic Use – Acute Care Sepsis Sepsis: Cultures Blood cultures … critical component of sepsis management8 Daily assessment of patient status, source of infection, and culture … Three scenarios: No evidence of infection and antibiotics can be stopped Evidence of infection and culture … data are available to guide narrowing of therapy Evidence of infection and no culture data are available … have grown, narrow based on culture results 22 AHRQ Safety Program for Improving Antibiotic Use

2616. 5 Tk2 P2T8-Sample Antibiogram Phase 2 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P2T8-Sample_Antibiogram_Phase_2.pdf
      May 01, 2014 - : Of XXX cultures used to make the antibiograms, XX% were urine cultures, YY% were wound cultures, … and Z% were sputum cultures. … • The leading organisms for positive urine cultures were: o E. coli: XX% of urine cultures o Enterococcus … Urinary tract infections (UTIs) from gram-negative organisms • XX% of positive urine cultures were due … Gram positives • XX of XX (XX%) S. aureus cultures were MRSA.

2617. Technical Interventions To Prevent CAUTI | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/guides/implguide-pt3.html
      October 01, 2015 - The following are appropriate conditions for urine culture use: Evaluation of sepsis without a clear … , evaluate current processes for obtaining urine cultures (e.g., avoid urinalysis or urine cultures as … Have periodic audits on urine culture use in intensive care units to look for trends, especially if CAUTI … avoid inappropriate antimicrobial use in catheterized patients is to refrain from obtaining a urine culture … When a urine culture is positive in a catheterized patient who has no symptoms of infection, do not treat

2618. 5 Tk2 P3T8-Sample Pocket Card Long Version Phase 3 (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_P3T8-Sample_Pocket_Card_Long_Version_Phase_3.doc
      May 01, 2014 - Version 9” (4 @ 2.25”) x 3.25” Key Findings From the Antibiograms · Most of our data come from urine cultures … : Of 192 cultures used to make the antibiograms, 93% were urine cultures, 6% were wound cultures, and … 1% were sputum cultures. … · The leading organisms for positive urine cultures were: · E. coli: xx% of urine cultures · Enterococcus … Gram Positives · 11 of 14 (xx%) Staphylococcus aureus cultures were Methicillin-resistant Staphylococcus

2619. Appendix A. Literature Review | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraapa.html
      April 01, 2018 - During operative process, culture collected. … Culture considered positive if > 30cfu of bacteria identified. … During the operative procedure, a semiquantitative culture was collected from subcutaneous fat in the … positive cultures had colony counts that were too numerous to count. … , compared with 82 of 1,576 patients (5.2%) with negative cultures.

2620. Assessment and Management of the Resident With a Suspected Urinary Tract Infection | Agency for Healthcare Research and Quality
      www.ahrq.gov/antibiotic-use/long-term-care/best-practices/uti-assess.html
      June 01, 2021 - Poster – Collecting Bacterial Cultures (PDF, 202.3 KB) Poster – Urine Culture Collection (PDF, 178 … KB) One-Page Document – Collection of Microbiological Cultures (PDF, 159.2 KB)   The materials