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Showing results for "culture of safety".

9681. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness | PSNet
      psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
      February 01, 2014 - We have this culture such that people are hypersensitive about interrupting someone, but somebody needs … focusing on advancing our understanding of diagnostic safety. … We have made extensive progress in changing the culture in hospitals and other health care institutions … of safety to ensure that evidence-based care is delivered. … Perspective What We've Learned About Leveraging Leadership and Culture

9682. Computerized Provider Order Entry | PSNet
      psnet.ahrq.gov/primer/computerized-provider-order-entry
      March 15, 2025 - New Safety Concerns: Implementation Issues and Workflow Impact of CPOE The implementation of CPOE has … and vulnerability testing, to achieve the safety potential of CPOE. … new types of errors Unexpected changes in an institution's power structure, organizational culture, … Safety Primer . … patient safety.

9683. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49581/psn-pdf
      March 21, 2009 - threat to patient safety. … All too often the safety committee acts without the benefit of insightful input from the practitioners … individuals to penetrate or bypass the system's safety nets. … Safety Strategies Recommendations To decrease the probability of future errors involving the medication-use … patient care, move toward a culture that is collaborative and supports questions pertaining to drug

9684. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
      January 01, 2016 - Progress will require not only advances in the science but also changes to today's culture, which inhibits … Patient Safety Centers of Inquiry (PSCI). … Washington, DC: VA National Center for Patient Safety, US Department of Veterans Affairs; 2015. … It's my own belief that the major factor was the perception that we were doing okay in regard to diagnosis … We need to get much better feedback if we want to excel at this, and we need to create a culture where

9685. In Conversation With… Gordon Schiff, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
      February 26, 2025 - Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, … Associate Professor of Medicine at Harvard Medical School, and Quality and Safety Director for the Harvard … safety movement? … Getting better follow-up and feedback and creating the conditions that support such a culture of partnership … Those kinds of things will create a culture, foster the preconditions for better diagnosis, and allow

9686. Project BOOST Increases Patient Understanding of Treatment and Follow-up Care | PSNet
      psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
      February 26, 2025 - can tailor components to align with their organizational needs, priorities, available resources, and culture … Williams was awarded one of 17 Partnerships in Implementing Patient Safety (PIPS) grants offered by the … implementation kits and tools that facilitate the adoption of patient safety interventions. … AHRQ Patient Safety E-Newsletter . 2007 Aug 6;(34). … March 8, 2023 Safety of elderly fallers: identifying associated risk factors for 30-day

9687. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33562/psn-pdf
      September 15, 2024 - Such teams have become a widely used patient safety intervention due in large part to their inclusion … conceptually attractive patient safety interventions supported by anecdotal evidence of benefit and … Bedside staff are encouraged to call the team when any of a number of prespecified criteria (Table 2 … RRSs are very popular among nursing staff and can contribute to detection of underlying patient safety … https://psnet.ahrq.gov/primer/national-patient-safety-goals

9688. The racial disparities in maternal mortality and impact of structural racism and implicit racial bias on pregnant Black women: a review of the literature. | PSNet
      psnet.ahrq.gov/issue/racial-disparities-maternal-mortality-and-impact-structural-racism-and-implicit-racial-bias
      July 13, 2009 - on pregnant black women: a review of the literature. … a patient safety and public health crisis . … This literature review of 42 articles highlights the importance of cultural competence and disparities … November 25, 2020 Diagnostic safety: needs assessment and informed curriculum at an academic … November 13, 2024 Impact of patient safety bundle and team-based training on obstetric

9689. Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. | PSNet
      psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
      January 19, 2022 - January 19, 2022 Identifying errors and safety considerations in patients undergoing … April 21, 2021 Room of hazards: a comparison of differences in safety hazard recognition … reactions using safety event reports across hospitals. … December 9, 2020 Allergy safety events in healthcare: development and application of … administration, and closed-loop electronic medication management systems on work processes and safety

9690. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49465/psn-pdf
      December 22, 2021 - The Institution's Response After a discussion of this case at the clinic's monthly safety and quality … safety performance of the delivery system. … The safety practices described in this case study (eg, informing the patient of the error, assessing … ) indicate that a healthy culture of safety is in place to respond to safety incidents. … Institute of Medicine. Committee on Data Standards for Patient Safety.

9691. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33684/psn-pdf
      May 01, 2009 - Patient Safety: A Perspective from Office Practice May 1, 2009 Baron RJ. … Patient Safety: A Perspective from Office Practice. PSNet [internet]. 2009. … Many potential and actual safety problems occur there as well.(1) Yet patient safety literature and … Patient Safety Issues in the Office-Based Setting. … The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA.

9692. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853772/psn-pdf
      September 27, 2023 - psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care https://psnet.ahrq.gov//#9 Cultivating a culture … of communication and collaboration across providers plays a vital role in patient safety by decreasing … Systems Change Needed Patient safety is an inherent responsibility of the clinical microsystem. … This approach recognizes that patient safety is the result of the collective efforts of many individuals … From the Safety-II perspective, it would be useful to understand the resilience of the discharge process

9693. In Conversation with... Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS | PSNet
      psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
      December 14, 2022 - intention is a broad definition, including people, knowledge, equipment, physical spaces, protocols, culture … Sarah Mossburg: We talked about some of the benefits of resilient healthcare and Safety-II. … really speaks to the Safety-II concept of safety as adaptation. Ellen Deutsch: Yes. … socio-technical systems, the physical environment, the protocols, the culture, the equipment, and the … improve the safety of the care we deliver.

9694. Peripheral IV in Too Long | PSNet
      psnet.ahrq.gov/web-mm/peripheral-iv-too-long
      September 15, 2011 - Blood cultures drawn at the time grew methicillin-resistant Staphylococcus aureus (MRSA), most likely … 3165 patients, however, the majority of phlebitis cases were culture-negative, suggesting the local … Improving the safety of peripheral intravenous catheters. BMJ. 2008;337:a630. … Safety of prolonging peripheral cannula and i.v. tubing use from 72 hours to 96 hours. … September 15, 2011 An examination of Leapfrog safety measures and Magnet designation.

9695. CE/MOC Quizzes | PSNet
      psnet.ahrq.gov/cme
      February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations A man with a … The commentary provides an overview of the clinical manifestations of intraoperative durotomy, intra- … management strategies to address intraoperative durotomy and CSF leaks, and approaches to ensuring patient safety … The commentary highlights the importance of thorough neurological investigation of patients presenting … and how a culture of safety can enable care team members to voice concerns about patient safety. 

9696. The Physical Environment: An Often Unconsidered Patient Safety Tool | PSNet
      psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
      November 21, 2018 - Below, we discuss some of the key findings from the Pebble partners as they relate to patient safety … Are specific resources needed, such as mock-up rooms or virtual tools, to integrate safety culture, process … Have the postoccupancy evaluations of safety outcomes been included as part of the organization's performance … The architecture of safety: hospital design. Curr Opin Crit Care. 2007;13:714-719. … July 11, 2018 Framework for direct observation of performance and safety in healthcare

9697. In Conversation with...Geri Amori, PhD | PSNet
      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. … the notion of safety science, patient safety, and proactive safety. … 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

9698. Annual Perspective: Topics in Medication Safety | PSNet
      psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
      April 27, 2022 - Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices … “medication error” as 1 of 22 nursing-sensitive issues that can affect patient safety outcomes. … The report recommended transitioning to a “Just Culture” in nursing school programs. … Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices . … of Healthcare Staff March 31, 2022 Perspectives on Safety

9699. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment | PSNet
      psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
      June 01, 2018 - latent patient safety threats before they harm a child. … In situ simulation: detection of safety threats and teamwork training in a high risk emergency department … BMJ Qual Safety. 2013;22:468-477. [go to PubMed] 8. … Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary … August 17, 2022 Influences of leadership, organizational culture, and hierarchy on raising

9700. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866395/psn-pdf
      July 23, 2024 - care processes with the goal of improving failure to rescue rates and overall patient safety.1 The … Innovation Patient Safety Focus A study was conducted on 84,730 patients from 2005 to 2007 using data … This shift in mindset can promote patient safety. … The team worked with the facilities department to ensure proper bed assembly, security, and safety and … Creating an environment where a culture of safety is incorporated into daily practice is the ultimate