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2861. Final Progress Report: Conference on Medical Error Communication and Dispute Resolution (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/liebman-hyman-report.pdf
      January 01, 2024 - regarding medical error and liability, possible legislative initiatives, changing the blame and shame culture

2862. Overview | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/intro.html
      October 01, 2014 - To accomplish this coordination, high-quality prevention requires an organizational culture and operational

2863. A Breakthrough Approach to Improving CAHPS Communication Performance (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/communication_2012_04_01_transcript.pdf
      January 01, 2012 - discussing some of the factors that are important to any quality improvement effort, such as organizational culture

2864. The “Never Antibiotic” Diagnoses: Acute Bronchitis – Facilitator Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/bronchitis-guide.docx
      September 01, 2022 - acute bronchitis, including chest x ray, spirometry, peak flow measurement, respiratory samples for culture

2865. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
      August 01, 2022 - In the CANDOR process, event analysis incorporates Just Culture and system and human factors causes of

2866. 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 - 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

2867. Making Healthcare Safer IV | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/making-healthcare-safer/mhs4/index.html
      May 01, 2025 - Making Healthcare Safer IV A Continuous Updating of Patient Safety Harms and Practices Making Healthcare Safer reports I, II, and III have shown a positive impact of patient safety practices on the reduction of medical errors. However, threats to patient safety are still emerging and evolving in a dynamic wor…

2868. Cross-Cutting Strategies To Advance PCORTF Priorities | Agency for Healthcare Research and Quality
      www.ahrq.gov/pcor/strategic-framework/cross-cutting-strategies.html
      July 01, 2023 - Cross-Cutting Strategies To Advance PCORTF Priorities Previous Page AHRQ tackles healthcare delivery challenges in myriad ways. Cross-cutting strategies are built on AHRQ’s core competencies and evidence-based methodologies and aligned with the PCORTF authorizations . The cross-cutting strategies will …

2869. PS Grantee | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/index.html?page=18
      January 01, 2024 - Grantee Final Reports: Patient Safety Final reports from research grants administered since 2000 on a variety of patient safety topics, such as measure development, medication safety, and diagnostic safety. The Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety subdivis…

2870. Navigating Hierarchy in the Clinical Setting: Working and Communicating with Others | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/navigating-hierarchy-slides.html
      December 01, 2017 - Navigating Hierarchy in the Clinical Setting: Working and Communicating with Others Slide Presentation Slide 1 Navigating Hierarchy in the Clinical Setting: Working and Communicating with Others Susan M. Hohenhaus, LPD, RN, CEN, FAEN Executive Director Emergency Nurses Association Slide 2 Learni…

2871. Module-10-Implementation-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-10-implementation-guide.pdf
      April 16, 2022 - Even more importantly, you'll need to determine if your organization has the culture and capacity to … • Assess Your organization's culture and willingness to make a change such as introducing a new hybrid

2872. Information to Help Hospitals Get Started (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_to_Use_Guide_508.pdf
      February 08, 2018 - To be effective, patient and family engagement must be integrated into the organizational culture.

2873. 3. What Are the Best Practices in Pressure Ulcer Prevention that We Want to Use? (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3a.html
      October 01, 2014 - This is a unit or facility culture issue that needs to be addressed systemwide.

2874. 3. What Are the Best Practices in Pressure Ulcer Prevention that We Want to Use? (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3a.html
      October 01, 2014 - This is a unit or facility culture issue that needs to be addressed systemwide.

2875. Final Progress Report: Caregiver innovations to reduce harm in Neonatal Intensive Care (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/thomas-report.pdf
      January 01, 2025 - Implications The implementation of a robust process improvement program helps create a culture of continuous … participants associated with the NICU and Parent Advisory Council (PAC) to examine perceptions, attitudes, beliefs … Use of parent-centered safety culture tool (PCSCT) assessment. … A parent-centered safety culture assessment was conducted with parents in the NICU from August to September … The unit culture improved as well to include verbal report of UPEs in different forums.

2876. Using-Health-It-To-Support-Qi (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/using-health-it-to-support-qi.pdf
      March 01, 2015 - Acknowledgements section. 3 • a practice culture … Factors supporting the use of health IT for QI in primary care Having a practice culture with a … exemplary uses and best practices to inspire and guide primary care practices seeking to create a culture … transformations—in the form of payment reforms and technical assistance—will help more practices adopt a culture

2877. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
      www.ahrq.gov/downloads/pub/advances/vol2/Schiff.pdf
      January 01, 2005 - and important, but represent an underemphasized and understudied area of patient-safety.1–8 This belief … The next day, blood cultures are growing gram negative organisms. … day when (a) review of laboratory data over the past year shows that patient had four prior blood cultures … surgery; it was only prevented by the fact that she was a Jehovah’s Witness and, because her religious beliefs

2878. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schiff.pdf
      January 01, 2005 - and important, but represent an underemphasized and understudied area of patient-safety.1–8 This belief … The next day, blood cultures are growing gram negative organisms. … day when (a) review of laboratory data over the past year shows that patient had four prior blood cultures … surgery; it was only prevented by the fact that she was a Jehovah’s Witness and, because her religious beliefs

2879. Hand Hygiene
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/infection-prevention/hand-hygiene/hand-hygiene.pptx
      March 01, 2017 - How can I help support a culture of safety around improving hand hygiene in our facility? … How can each of us help support a culture of safety around improving hand hygiene in our facility?

2880. The Four Es of Early Mobility: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/4es-early-mobility-slides.html
      February 01, 2017 - Execute (Adaptive) Frontline Staff: How will we implement early mobility at our hospital give local culture … Laminate cues and write custom goals when appropriate.