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psnet.ahrq.gov/node/39294/psn-pdf
January 03, 2017 - Patient handoffs: standardized and reliable measurement
tools remain elusive.
January 3, 2017
Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt
Comm J Qual Patient Saf. 2010;36(2):52-61.
https://psnet.ahrq.gov/issue/patient-handoffs-standardized-and-reliable-m…
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - this does for the people doing the analysis, and for the institutions where they work, is create a culture … privilege and confidentiality in a way that sets up the protected space that enables the creation of a culture … improving patient safety;
Utilization of patient safety work product for the purposes of encouraging a culture … and Administrators
Policy Makers
Legal and Policy Approaches
Error Reporting and Analysis
Culture
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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - They're very simply, if we hurt somebody through inappropriate medical care, it is the ethic and
culture … First with the culture change: peer review, for instance, has
traditionally meant that we wait until … So we have to
move this culture in tandem. We have to convince people that we care about them. … a few years ago—that
we should not look at personal accountability but instead create a blameless culture—was
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - Workplace culture and human resource availability are common barriers to best practices To understand … Numerous barriers to reporting exist including fear of consequences, a culture of blame, perception … errors in a user-friendly and non-punitive manner are needed, as are clear reporting guidelines and cultures … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Workplace
culture and human resource availability are common barriers to best practices. … • Numerous barriers to reporting exist including fear of consequences, a culture of
blame, perception … errors in a user-friendly and non-punitive
manner are needed, as are clear reporting guidelines and cultures … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - conferences at many institutions.( 10,14,20,21 ) These conferences historically have been extensions of the culture … A culture shift will be necessary to create a productive process for the provider sharing the medical … New culture for coping: turning to peer support after medical errors. American Medical News.
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - organizations can use to prevent these errors include teamwork training and efforts to improve the culture … An organizational culture of safety promotes teamwork and standard practice using the Glucommander and … assess glycemic control and monitor the processes that support good outcomes, including those related to culture
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - conferences at many
institutions.(10,14,20,21) These conferences historically have been extensions of the culture … A culture shift will be necessary to create a productive process for the provider sharing the medical … New culture for coping: turning to peer support after medical errors. American Medical
News.
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - A culture of huddles and debriefs encourages a culture of safety and improves situational awareness, … A comprehensive obstetrics patient safety program improves safety climate and culture
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - including higher surgeon volume, intensive care unit (ICU) presence and specialist staffing, strong safety culture … include reducing the number of patients per nurse; increasing nursing surveillance; and improving safety culture … Related Patient Safety Primers
Rapid Response Systems September 15, 2024
Culture
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - Gaining buy-in and successfully implementing read-backs is also easier when there is an organizational culture
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psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
June 29, 2020 - Pharmacists' Role in Error Reporting and Feedback A marker of a culture of safety is a blame-free environment
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - in care, including transitions in care, and offers communication tips regarding health literacy and culture
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psnet.ahrq.gov/node/33772/psn-pdf
September 01, 2014 - Beliefs are a factor. … Physicians and patients have
their beliefs about medicine and its possibilities and limitations. … RW: So the reasons for overuse include financial incentives, cultural beliefs, marketing, and production
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psnet.ahrq.gov/node/49562/psn-pdf
May 01, 2008 - the active involvement of the
anesthesia and nursing staff.(10)
It is likely that the traditional culture
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - are even more susceptible to misinterpretation, due to changing context or
differences in gender and culture … could limit staff
training time)
B
Goals, policies, and standards Probably not a factor -
Safety culture … and priorities
Reactive culture (eg, address problems only when they
occur) - Proactive approach would
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psnet.ahrq.gov/node/33865/psn-pdf
September 01, 2018 - that although individual behavior is important, contributory factors within the organizational
system—culture … As
you said, this might be measurements of staff safety culture or it might be a measure of incident … obvious but worth saying: To support patient involvement in patient safety
does require a different culture
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psnet.ahrq.gov/issue/cms-changes-reimbursement-hais-setting-research-agenda
May 03, 2018 - January 23, 2017
Perception of patient safety culture in pediatric long-term care settings
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psnet.ahrq.gov/issue/fda-advise-err-reported-medication-errors-veklury-remdesivir-emergency-use-authorization
July 01, 2020 - The differences between human error, at-risk behavior, and reckless behavior are key to a just culture
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psnet.ahrq.gov/issue/can-your-nurses-stop-surgeon
September 02, 2020 - This article traces the development of a safety culture in a large Illinois health care system and