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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-sops-overview-webcast-bakdash.pdf
June 02, 2025 - AHRQ’s Surveys on Patient Safety Culture® for New Users - Jonathan Bakdash
AHRQ’s Surveys on Patient … Safety Culture®
(SOPS®) Program
Jonathan Bakdash, Ph.D. … SOPS databases
• Conducts research to further the
measurement and understanding of patient
safety culture … • Develops resources to improve safety
culture in facilities
8
What is Patient Safety Culture … Patient Safety Culture
The beliefs, values, norms,
shared by health care staff
Determines
behaviors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/culture-checkup-tool.docx
May 01, 2017 - Culture Checkup Tool
Culture Checkup Tool
Problem statement: Improving safety culture in a patient … What is culture? … Attitudes reflect the norms, values, and beliefs in the unit and, in turn, create the culture. … Remember, attitudes reflect the norms, values, and beliefs in the unit and, in turn, create the culture … Review the unit patient safety culture assessment (e.g., Hospital Survey on Patient Safety Culture) results
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www.ahrq.gov/patient-safety/reports/liability/waever.html
August 01, 2017 - unanticipated issues. 4,6 However, limited empirical work examines linkages between organizational cultures … The Intersection of Liability and Patient Safety Culture
Patient safety culture and liability intersect … not fully reflected in existing culture measurement tools include aspects of “just culture,” such as … Recommendation 4: Examine sub-cultures and clearly define the perspective your metric is asking respondents … physicians, nurses, and administrators on several dimensions. 15 , 37,38 Despite documentation of sub-cultures
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psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation-improve-patient
April 03, 2005 - The action plan proposed by this project includes ensuring a just culture so staff feel empowered to … October 5, 2022
Leadership behaviors, attitudes and characteristics to support a culture … April 17, 2024
Nurse leader attitudes and beliefs regarding medical errors. … March 6, 2024
Rooting an error review process in just culture: lessons learned. … May 12, 2021
Why accountability sharing in health care organizational cultures means
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - Studies have shown that trained phlebotomists or blood culture teams have fewer contaminated blood cultures … only one of several blood culture sets will be positive. … contamination rates in the range of 3% per blood culture drawn. … or blood culture teams to obtain blood for culture rather than using random nursing personnel, nondegree … cultures at some institutions.
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www.ahrq.gov/news/newsroom/case-studies/cquips0606.html
October 01, 2014 - of the nation's largest health care providers, implemented AHRQ's Hospital Survey on Patient Safety Culture … that to better meet its needs, the survey was modified by dropping two question items, and adding one custom … With the belief that managers are responsible for setting the expectations and promoting the culture … These training sessions will delineate ways to promote a culture of patient safety and the importance … "This is a tool we plan to incorporate into the total culture of our organization."
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www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/blood-culture.html
October 01, 2024 - Implementation of MRSA Prevention
Fundamental Best Practices Up to half of all positive blood cultures … Discuss strategies to promote blood culture stewardship and reduce blood culture contamination. … Documents: Blood Culture Practices and Stewardship – Slides (PPTX, 11.2 MB) Blood Culture Practices … a decision-making algorithm for optimal use of blood cultures, with appropriate clinical indications … for initial and follow-up blood cultures in non-neutropenic populations.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/understanding-cms-patient-safety-measure-hospitals-webcast.pdf
July 08, 2025 - Patient Safety Culture
The beliefs, values, norms,
shared by health care staff
Determines
behaviors … ” pulse
survey using a custom
selection of composite
measures and single items
that are of most interest … item)
Hospital Management Support
Handoffs and Information Exchange
Option 2: Example of a Custom … item)
✓ Hospital Management Support
X Handoffs and Information Exchange
Option 2: Example of a Custom … Survey
Option 1: Full HSOPS 2.0 Survey to Selected Units or Selected Staff
Option 2: Example of a Custom
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www.ahrq.gov/news/newsroom/case-studies/cquips0703.html
October 01, 2014 - Military Hospitals Employ AHRQ Hospital Survey on Patient Safety Culture
Search All Impact Case Studies … The Department of Defense Patient Safety Program chose AHRQ's Hospital Survey on Patient Safety Culture … as an anonymous, Web-based initiative to assess staff attitudes and beliefs about patient safety, medical … To understand the status of patient safety culture in MHS facilities. … Twelve general areas of patient safety culture were assessed in the survey.
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/when-to-order/worksheet.html
May 01, 2017 - National Content Series Discussion Guide - The Culture of Culturing: The Importance of Knowing When To … Order Urine Cultures
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Discussion
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www.ahrq.gov/hai/tools/clabsi-cauti-icu/overcome/culture.html
April 01, 2022 - Culture
A strong patient safety culture supports a learning environment and invites diverse input … Use these tools to help your team make lowering infections part of your culture. … Examples of common barriers that inhibit developing this culture are ineffective action from leaders,
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-facilitator-guide.docx
June 01, 2021 - Have we collected appropriate cultures and diagnostic tests before starting antibiotics? … The prescriber also considered part of Moment 2; she ordered appropriate cultures before prescribing … They are not using appropriate diagnostic criteria before ordering urine cultures. … This leads to unnecessary antibiotics prescribed for residents with positive urine cultures. … Adaptive Problems
SAY:
Adaptive problems are problems for which solutions require a change in attitudes, beliefs
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psnet.ahrq.gov/issue/patient-safety-dialogue-evaluation-intervention-aimed-achieving-improved-patient-safety
December 09, 2020 - Patient Safety Dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture … Patient safety dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture … A cross-sectional survey of patient perceptions and beliefs. … May 31, 2017
Are measurements of patient safety culture and adverse events valid and … February 15, 2011
Assessing and improving safety culture throughout an academic medical
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.html
March 01, 2017 - T.E.A.M.S. infographic
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Culture … consists of values, attitudes, and beliefs that can have an impact on resident safety, care outcomes … Culture influences how change can occur. … Re-evaluate your culture annually. Are the intended changes happening? … M
Meet Monthly
Evaluating culture is an ongoing process.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
January 01, 2004 - Culture of safety
James Reason20 defines “culture” as “shared values (what is important) and
beliefs … Safety culture goals
1. Shared values and beliefs about safety within the organization
2. … Culture of reporting
5. Learning culture
6. “Just” culture
7. … A
common belief system is essential to develop a safe culture. … Safety culture strategies and the development of a common belief system—
along with an anonymous and
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psnet.ahrq.gov/issue/culture-resistance
September 19, 2016 - Newspaper/Magazine Article
Culture of resistance. … Citation Text:
Culture of resistance. Berens MJ; Armstrong K. … Linkedin
Copy URL
Cite
Citation
Citation Text:
Culture
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psnet.ahrq.gov/issue/association-between-organizational-culture-and-ability-benefit-just-culture-training
August 04, 2021 - Study
The association between organizational culture and the ability to benefit from … "just culture" training. … The Association Between Organizational Culture and the Ability to Benefit From "Just Culture" Training … culture may be a barrier to successful culture change. … The Association Between Organizational Culture and the Ability to Benefit From "Just Culture" Training
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www.ahrq.gov/sites/default/files/2024-07/etchegaray2-report.pdf
January 01, 2024 - Final Progress Report: Parent Perceptions of NICU Safety Culture: Parent-Centered Safety Culture Tool … Parent Perceptions of NICU Safety Culture: Parent-Centered Safety Culture Tool
Project Team: Jason … Key Words: NICU parents, safety culture, infant safety, parental roles
1. … Aim 2: To develop and psychometrically test a survey to measure parent perceptions of safety culture … Parent Perceptions of NICU Safety Culture: Parent-Centered Safety Culture Tool
Structured Abstract
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psnet.ahrq.gov/issue/studying-organisational-cultures-and-their-effects-safety
April 20, 2014 - Commentary
Studying organisational cultures and their effects on safety. … Studying organisational cultures and their effects on safety. … Studying organisational cultures and their effects on safety. … January 2, 2017
Measuring safety culture in healthcare: a case for accurate diagnosis … November 24, 2010
The safety culture in a children's hospital.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/improvement-slides.pptx
November 01, 2019 - Program for Improving Antibiotic Use – Acute Care
4
Adaptive Problems
Require a change in attitudes, beliefs … and beliefs
Identifies system opportunities to prevent harm from occurring again
6
Identifying Targets … Have I ordered appropriate cultures before starting antibiotics? … Sputum cultures grow a pan-susceptible E. coli.
Not necessary to continue broad-spectrum therapy. … A sputum culture is pending.
In this case, the diagnosis is highly likely to be heart failure.