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digital.ahrq.gov/sites/default/files/docs/citation/r21hs025238-xie-final-report-2020.pdf
January 01, 2020 - To optimize blood
culture utilization and reduce its negative impacts on healthcare quality, safety … We have been continuously collecting data on the use of blood cultures (e.g., blood cultures rate … (Safety concern) Why did both clinician and CDS
tool fail to capture signs of sepsis? … CDS √
Clinician X
(Safety concern) What signs of sepsis did CDS tool
capture that clinician failed … Initiative for Patient Safety (SEIPS) model23 to identify
work system factors influencing blood culture
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digital.ahrq.gov/sites/default/files/docs/page/2006Reiling_052411comp.pdf
January 01, 2005 - Push
• Standardize Work
• Visual Control
• Proven Technology
• Culture of stopping to fix problems
• … Safety
• Shared Values and Beliefs about Safety within the
Organization
• Always Anticipating Precarious … Events
• Informed Employees and Medical Staff
• Culture of Reporting
• Learning Culture
• “Just” Culture … culture survey
•Length of stay
•Cost
•Trending of
hospital survey data
and financial data
since … Lean Principles
Process Recommendations
Creating a Culture of Safety
2005: Baseline Research Guiding
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digital.ahrq.gov/sites/default/files/docs/cds-slides-10192021.pdf
October 19, 2021 - A usability and safety analysis of
electronic health records: a multi-center study. … A usability and safety analysis of
electronic health records: a multi-center study. … blood cultures resulting in
► Additional tests
► Unnecessary antibiotic use
► Prolonged hospitalization … Dissemination of the blood culture checklist
39
HFE Applications
• Integration of the blood culture … the blood culture checklist into
electronic health records (EHRs)
• Dissemination of the blood culture
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015270-hayden-final-report-2008.pdf
January 01, 2008 - initiatives to enhance the “culture of safety”:
14. … Methods
Culture of Safety Study
To assess the evolving culture of safety at the hospital, the project … The disparity between the lack of change in beliefs that surround reporting of adverse events
and near … the importance of good communication to
safety and a belief that communication systems have improved … However, it is reasonable to consider that staff attitudes toward
patient safety, and their beliefs
-
digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015284-reiling-final-report-2008.pdf
January 01, 2008 - of HIT and
the design of a new hospital focused on safety, enhancing safety culture and safety driven … reality and benefits of a safety culture. … a safety culture. … The Culture of Safety. Speech by Carolyn M. … Safety culture and organizational issues:
creating a culture of patient safety through innovative
hospital
-
digital.ahrq.gov/ahrq-funded-projects/comprehensive-information-technology-it-solution-quality-and-patient-safety/annual-summary/2009
January 01, 2009 - The hospital has embarked on a multiyear process to grow a culture of safety to support safe, consistent … the hospital’s culture of safety by changing staff attitudes and perceptions, particularly related to … Final survey data were collected regarding attitudes toward health IT and the hospital’s culture of safety … Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital … of safety.
-
digital.ahrq.gov/ahrq-funded-projects/improving-healthcare-quality-information-technology/annual-summary/2008
January 01, 2008 - In addition, SVMC undertook a major initiative to improve organizational culture around patient safety … Specific Aims
Assess the development of a "culture of safety" through educational programs, administrative … of a "culture of safety" throughout the organization. … , the importance of access to information, and a more frequently articulated sense that a "culture of … the importance to safety of good communication and a belief that communication systems have improved
-
digital.ahrq.gov/track-7-working-conditions-challenges-patient-safety
January 01, 2023 - of medication safety; illustrations of methodologies for conducting time-motion studies evaluating how … safety culture and working conditions on providers and patients in the inpatient and outpatient settings … Discussions will focus on techniques for measuring and assessing various types of safety culture, the … relationship of safety culture measures to organizational characteristics and patient outcomes in US … Presenters will describe NASA's behavior-based culture change efforts following the 2003 Space Shuttle
-
digital.ahrq.gov/ahrq-funded-projects/midcoast-maine-patient-safety-it-integration
January 01, 2023 - Midcoast Maine Patient Safety With IT Integration
Project Description … Acute Care
Home Health Care
Hospice Care
Long-Term Care
Health Care Theme
Patient Safety … health care system and develop an effective intervention strategy that takes into account organizational culture … The study included three assessments - quality/patient safety; organizational culture; and technology … successful, the implementation needed to consider the socio-technical system, shift the organization culture
-
digital.ahrq.gov/sites/default/files/docs/citation/uc1hs015236-jose-final-report-2008.pdf
January 01, 2008 - and safety culture. … on Patient Safety which measures 9 dimensions of safety culture and 2
overall patient safety outcomes … Safety Culture Survey. … of the EMR, and clinical staff safety culture. … Promoting a culture of safety in pediatric
hospitals: monitoring the effect of patient safety
initiatives
-
digital.ahrq.gov/sites/default/files/docs/publication/uc1hs014920-bellamy-final-report-2007.pdf
January 01, 2007 - Hospital Survey on Patient Safety Culture, 4) calculation of WV-
specific PSIs (annually), 5) formation … Patient Safety Culture Survey: The AHRQ Hospital Survey on Patient Safety Culture was
distributed … 100%
Figure 2
Hospital Survey on Patient Safety Culture CAH vs. … Getting the Most Out of the AHRQ Hospital Survey on Patient Safety Culture. … “Assessing the Culture of Safety in Rural West Virginia,” 4th Annual Patient Safety
Conference, Charleston
-
digital.ahrq.gov/sites/default/files/docs/page/2006McColm_051111comp.pdf
June 16, 2021 - Health Information Technology & Patient Safety
Health Information Technology &
Patient Safety
Denni … offices
• 1,550 employees
• 98 physicians
Project Infocare
• EMR that crosses continuum
• 100% use of … CPOE
• No paper charts
HIT/Patient Safety Challenges
• Organization culture
• Temptation to automate … Challenges
• Team approach
• Process redesign
• Proactive communication
• Education
• Common measures of … Fast Facts
Project Infocare
HIT/Patient Safety Challenges
Overcoming those Challenges
The Future
-
digital.ahrq.gov/2018-year-review/research-dissemination/journals
January 01, 2018 - multidisciplinary stakeholders and a project champion, 3) collection and sharing of blood culture data … Across the three units, blood culture rates significantly decreased by 32 percent, and the rate of cultures … issue of Health Affairs , “Patient Safety,” includes a comprehensive look at the best and latest patient … safety research. … The articles explore a broad range of safety initiatives, including the use of health IT to reduce medication
-
digital.ahrq.gov/ahrq-funded-projects/health-information-technology-support-safe-nursing-care/annual-summary/2008
January 01, 2008 - to continuity, safety, and quality of care. … assess goals of the system, including mindfulness; heedful interrelating; and a culture of safety, trust … types; geographic locations; unit physical setups, including large, small, ICU, step-down, and regular; cultures … including workflow observation and a survey of the culture of safety, while other analytic tools were … the team’s collective mind, improving the culture of patient safety.
-
digital.ahrq.gov/ahrq-funded-projects/comprehensive-information-technology-it-solution-quality-and-patient-safety-3
January 01, 2023 - Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital … Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital … Project Name
Comprehensive Information Technology (IT) Solution for Quality and Patient Safety
-
digital.ahrq.gov/track-2-implementation-issues-patient-safety-and-health-it
January 01, 2023 - Track 2: Implementation Issues in Patient Safety and Health IT
Featured … and "Establishing a culture of safety in critical access hospitals. … highlight four organizations and the process-oriented changes implemented in each, providing for a safer culture … The evolving role of pharmacists on an ED team and a safety toolkit will be included. … -2:30 Congressional Hall B
Track 2-V e-Prescribing Standards
Assuring the interoperability and safety
-
digital.ahrq.gov/sites/default/files/docs/page/Keenan.ppt
January 01, 2004 - care
To demonstrate that implementation of the HANDS Method increases the safety culture of diverse … a strong safety culture
Routinely engages in heedful interrelating with colleagues during patient … Focus groups
6 mo. 12 mo, 24 mo
Aim 2
HANDS CPP Method Enhances Safety Culture
Criterion Measures … – Safety Culture
Trust survey,
Pre-HANDS, 12 mo post, 24 mo post
Culture survey,
Pre-HANDS, 12 … CULTURE
Improved
communication
Reduced errors
Continuity of care
Positive patient
outcomes
-
digital.ahrq.gov/sites/default/files/docs/lesson/09-0012-ef-telehealth.pdf
December 01, 2008 - Using Telehealth to Improve Quality and Safety
Using Telehealth to Improve
Quality and Safety
Findings … and evaluation of various information technologies that were intended to improve the
quality, safety … Members of the practice team received distance education
and training about patient safety and electronic … and culture of safety both pre and postteleICU implementation. … of safety following teleICU implementation, with nurses reporting the greatest
improvements.
-
digital.ahrq.gov/ahrq-funded-projects/comprehensive-information-technology-it-solution-quality-and-patient-safety
January 01, 2023 - No statement in this report should be construed as an official position of AHRQ or of the U.S. … technologies to improve patient safety and quality as well as increase efficiency of all operations. … No statement in this report should be construed as an official position of AHRQ or of the U.S. … as a tool for improving safety culture in a pediatric hospital system. … Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital
-
digital.ahrq.gov/principal-investigator/jose-jim
January 01, 2023 - Using staff perceptions on patient safety as a tool for improving safety culture … Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital … Evaluating usability of a commercial electronic health record: a case study. … Evaluating usability of a commercial electronic health record: a case study. … (Prepared by Children's Healthcare of Atlanta, Inc. under Grant No. UC1 HS015236).