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Showing results for "culture of safety".

2121. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-West_102.pdf
      March 31, 2008 - to improve patient safety. … Introduction Patient safety reporting systems (PSRS) are useful tools to understand the scope of errors … ASIPS Patient Safety Reporting System The core of the ASIPS PSRS is a Web-based data collection and … classification Harm category Example Known clinical harm to the patient A positive herpes simplex culture … medical errors.26 Until we can create a culture that embraces learning from our mistakes, including

2122. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
      May 05, 2008 - a culture of safety. … Understanding these metrics requires individuals to avoid applying theories or models of safety to health … Frush); Patient Safety Office, Duke University Health System (Mr. Alton, Dr. … Safety in the operating theatre – Part 2: Human error and organisational failure. … The impact of culture on technology.

2123. Final Progress Report: Workshop on Consumer Engagement in Selected Patient Safety Topics (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/hatlie-report.pdf
      January 01, 2024 - that human beings co-create what is thought to be “reality” through language, thoughts, images, and beliefs … - 6 - thoughts, beliefs, and language that shift current mental models about what is (“patients … engage participants as creative partners, perhaps prompting them to re-examine their own thoughts and belief … disclosed and/or a report to the National Practitioner Data Bank (However, there should also be a “just culture … Just culture = does not tolerate reckless disregard for the consequences of an action.

2124. Final Progress Report: : State of the Science on Safe Medication Administration (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/barnsteiner-report.pdf
      January 01, 2024 - a “just culture of safety” • Partner with professional and educational groups and organizations to ensure … teams for collaborative learning from errors • Use inter- and intradisciplinary models to change team cultures … How do safety climate, error reporting, and root cause analysis affect patient safety, quality of care … Patient Safety at University of Pennsylvania School of Nursing. … a “just culture of safety” Lack of interdisciplinary collaboration and communication Nurses’ working

2125. Section 4: Ways To Approach the Quality Improvement Process (Page 2 of 2) | Agency for Healthcare Research and Quality
      www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/sect4part2.html
      January 01, 2020 - In a Lean culture, the focus is on interdisciplinary teams, where leaders are coaches and enablers. … of defects. … The Team Strategies and Tools To Enhance Performance and Patient Safety (TeamSTEPPS ® ) For many health … TeamSTEPPS is an evidence-based training program designed to improve quality and safety by enhancing … Implementing and validating a comprehensive unit-based safety program.

2126. C | Agency for Healthcare Research and Quality
      www.ahrq.gov/topics/c.html
      June 12, 2025 - Effectiveness Comparative Health System Performance (CHSP) Initiative Comprehensive Unit-based Safety … Program (CUSP) Consumer Assessment of Healthcare Providers and Systems (CAHPS) COVID-19 Cultural

2127. Making It Work Tip Sheet: Spot Coaching To Support Behavior Change (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/spot-coaching.pdf
      April 01, 2022 - Making It Work Tip Sheet: Spot Coaching To Support Behavior Change AHRQ Safety Program for Intensive … bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) and improve safety … culture at the unit level. … Rarely is behavioral change a function of not knowing what to do; it is a problem of making conscious … at shift change, during reviews of adverse events or data updates, and during rollout of new practices

2128. Apply CUSP | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/modules/apply/index.html
      July 01, 2018 - Apply CUSP The Apply CUSP module of the CUSP Toolkit introduces Just Culture principles, which … This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit, … Version ) Team Check-up Tool [ - 227.5 KB] ( Accessible Version ) Video Understand Just Culture

2129. Slide 1
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/breaking-down-barriers-051215.pptx
      February 01, 2015 - 2 Hospital staff provide ongoing support and expertise (r/t CAUTI prevention, catheter use and safety … culture) 2 Polling Question What is your role at the hospital? … Develop a culture where evidence-based practice is recognized and rewarded. … 22 22 Other Strategies to Improve Execution A non-punitive culture Visible and supportive leadership … Comprehensive Unit-based Safety Program (CUSP) to Reduce Catheter-Associated Urinary Tract Infection

2130. The Relationship Between Hospital Workload and Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/weissman-rothschild-report.pdf
      January 01, 2024 - The Relation of Hospital Workload to Patient Safety: Final Report to AHRQ Purpose (Objectives of Study … However, seven of those infections had positive microbiology culture results that could have been used … The specimen codes used by those cultures were not codes used by the computer logic to identify wound … Thus, seven wounds were missed by computerized surveillance when study patients had positive culture … terms used for specimen and body site screening by computer surveillance were not included in those culture

2131. Best Practices for Web-based SOPS Surveys - Famolaro Slides (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-bestpractices-web-sopssurveys-famolaro.pdf
      September 01, 2020 - , MBA Senior Study Director and SOPS Database Manager User Network for the AHRQ Surveys on Patient Safety … Culture (SOPS) Westat 12 Use of Web in SOPS Surveys 25% 45% 76% 83% 2007 2010 2014 2018 % … ► Do the majority of providers and staff have email addresses and access to computers? … 18-24 months • Consider planning your administration around specific events ► During March Patient Safety … Grid Format 22 Incorrect Example of Grid Format 23 Incorrect Example of Grid Format 24 Incorrect

2132. Antibiotic Stewardship Helps Protect Newborns in Neonatal Intensive Care Units | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/939.html
      November 01, 2024 - Highlights From AHRQ’s Patient Safety Network . Register for Upcoming AHRQ Webinars . … Highlights From AHRQ’s Patient Safety Network AHRQ’s Patient Safety Network (PSNet) highlights journal … articles, books and tools related to patient safety. … Nurse burnout and patient safety, satisfaction, and quality of care: a systematic review and meta-analysis … Family medicine presence on labor and delivery: effect on safety culture and cesarean delivery.

2133. AHRQ and the Patient-Centered Outcomes Research Institute Collaborate to Train a New Generation of Learning Health System Scientists | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/blog/ahrqviews/ahrq-pcori-collaborate.html
      February 01, 2023 - system scholars trained; more than 400 publications authored by trainees; and numerous partnerships with safety-net … vital to the success of these efforts. … the breadth of backgrounds and cultures of the communities it serves and enable research that accelerates … the evolution of integrated learning health systems. … Valdez is Director of AHRQ. Dr. Cook is the Executive Director of PCORI.

2134. Study Finds Association Between Smoking and Chronic Pain | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/938.html
      November 01, 2024 - Highlights From AHRQ’s Patient Safety Network . New Research and Evidence From AHRQ . … Highlights From AHRQ’s Patient Safety Network AHRQ’s Patient Safety Network (PSNet) highlights journal … articles, books and tools related to patient safety. … knowledge related to patient safety culture at the nursing home front line: cocreative process study … Perception of medication safety-related behaviors among different age groups: web-based cross-sectional

2135. Tools To Help Mitigate Device Risk | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/phys-championsgd/section8.html
      October 01, 2015 - Device-Associated Infections Resident Physicians as Safety Champions Sustainability Preventing … It builds the capacity to address safety issues by combining clinical best practices and the science … of safety. … , quality and safety in health care.  … Example of TeamSTEPPS Pocket Guide

2136. Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure Ulcers in Nursing Home Environments (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Teigland.pdf
      March 01, 2004 - Introduction This study, which started in October 2001, is one of the 22 patient safety projects funded … Informatics to Promote Patient Safety (CLIPS), and is one of seven in the area of long term care (LTC … In addition, a resident safety culture survey will be administered to a sample of high and low use/integration … facilities to investigate whether nursing home safety culture explains differences in use of the risk … Evaluating the culture of safety. Qual Saf Health Care 2003;12:401. 37.

2137. Contact Precautions for MRSA Prevention - Webinar slide notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/017-contact-precautions-webinar-slides-notes.docx
      October 01, 2024 - Contact Precautions for MRSA Prevention - Webinar slide notes AHRQ Safety Program for MRSA Prevention … on prior clinical culture results. … from active surveillance cultures to decide which patients require isolation precautions. … Isolating newly admitted patients until the surveillance culture result is available can prevent MRSA … included: protecting yourself, protecting patients, peace of mind/feelings of safety, protecting your

2138. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Electronic Fetal Monitoring (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/safe-electronic/tool_safe-e-fetal-monitoring.docx
      May 01, 2017 - The key safety elements are presented within the framework of the Comprehensive Unit-based Safety Program … Key Perinatal Safety Elements Standardize When Possible (CUSP Science of Safety) Key Perinatal Safety … Standardize When Possible (CUSP Science of Safety) (continued) Key Perinatal Safety Elements Examples … Create Independent Checks (CUSP Science of Safety) Key Perinatal Safety Elements Examples Provide … Fetal monitoring: creating a culture of safety with informed choice.

2139. Part Two: Removing the Obstacles to Practice Change (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/ena-slides/part2a.html
      October 01, 2015 - Changing the culture and generating practice change needs to come from within. … Enter the role of nurse champion, who can be instrumental in changing the culture and shaking up the … Slide 122 The Joint Commission. (2008) National Patient Safety Goals. … tracks the workload objectively, and this may help alleviate conflict and contribute to changing the culture … Collecting organized data "Our problem" Tracks the workload Alleviate conflict Contribute to culture

2140. Presentation: Program Overview
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/4es-early-mobility-slides.pptx
      January 01, 2017 - Presentation: Program Overview The Four Es of Early Mobility AHRQ Safety Program for Mechanically … No. 16(17)-0018-50-EF January 2017 Four Es of Early Mobility ‹#› AHRQ Safety Program for Mechanically … Four Es of Early Mobility ‹#› AHRQ Safety Program for Mechanically Ventilated Patients Four Es of … STAFF EARLY MOBILITY Execute ADAPTIVE How will we implement early mobility at our hospital give local culture … communicate daily mobility goals Place near patient on white board, door, or bedside Laminate cues and write custom