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8621. Module 1: Preventing Pressure Injuries in Hospitals (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange.docx
      July 12, 2017 - The mindset is that we develop a culture of safety for our patients, and prevention processes are ongoing … We create a culture that focuses on safety, and we are constantly aware of the possibility of failure … These are all important issues for a positive safety culture. … The Team continues to have goals that are aligned with the organization’s culture and goals of preventing … Educating new staff in evidence-based practices ensures that all staff are aware of the culture of safety

8622. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33650/psn-pdf
      May 01, 2007 - A more open culture, in which errors or service failures can be reported and discussed. … To drive up reporting rates, the NPSA also began to work on ways to change the culture from one of blame … Tools, techniques, and training packages have also been developed and rolled out in safety culture assessment

8623. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73999/psn-pdf
      October 27, 2021 - Human factors of training and culture must also be considered. … Finally, the culture within the institution should be supportive and protective of personnel who report … Trainee supervision and institutional culture should encourage error reporting and prioritizing patient

8624. Two-Day Training Content | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/intro/teach/two-day.html
      January 01, 2024 - Sustainability: Explain that having a strong safety culture, aligning incentives, and maintaining and … inadequate clinical or technical proficiency, chronic major staff shortages, or an overall organizational culture … Achieving positive results requires effective implementation and a sustained commitment to a culture

8625. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33832/psn-pdf
      April 01, 2017 - When I got a job at Michigan, I had known that Karl had done his work on organizational culture as a … psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd https://psnet.ahrq.gov/issue/organizational-culture-source-high-reliability … around crisis management, Tylenol, etc. rather as a way of doing work and setting an organizational culture

8626. Patient Safety 101 | PSNet
      psnet.ahrq.gov/primer/patient-safety-101
      January 16, 2025 - The concept of just culture , now widely used in health care, emphasizes that most errors result from … Further aspects of this issue are discussed in the Culture of Safety Primer and in a 2024 Perspective … focus on enhancing patient and caregiver engagement, tracking and sharing safety data, promoting a culture

8627. Six Building Blocks How-To-Implement Toolkit: Monitor and Sustain Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-monitor.pdf
      April 20, 2021 - familymedicine.uw.edu/improvingopioidcare/wp-content/uploads/sites/9/2019/05/Sustainability_2019-05-20.docx Culture … If possible, integrate opioid management into a culture of patient safety and continuous improvement … Celebrate Successes Plan Next Steps Think Through Challenges to Sustainability Engagement Education Culture

8628. Partnering to Improve Patient Safety in Rural WV | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/partnering-improve-patient-safety-rural-wv
      January 01, 2023 - benchmarking data on events (quarterly); 3) administration of the AHRQ Hospital Survey on Patient Safety Culture … for less than 3 percent of electronic safety flags, leaders are trying to change their organizational culture

8629. Learning from Errors in Ambulatory Pediatrics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
      February 01, 2004 - This sort of change, and development of “a culture of learning,” is an important step toward developing … This is another example of how the development of a “culture of learning” might lead to a safer health … It is a widely held belief that medical errors are a significant problem, yet it is difficult to estimate … Training in error identification and error mechanisms, and in the systems, culture, conditions, and … Each practice must recognize how to assess its own culture and design, and conduct effective tests

8630. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50876/psn-pdf
      April 22, 2021 - Veterans Accountability Improvement Act. April 22, 2021 SB 1307, 117th Congress: 2021. https://psnet.ahrq.gov/issue/veterans-accountability-improvement-act Reporting clinicians who exhibit practice behaviors that are detrimental to safety is challenged by system and cultural norms. This legislation aims to strengt…

8631. Tips on Writing a Report on Health Care Quality for Consumers | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/resources/writing/index.html
      July 01, 2011 - Tips on Writing a Report on Health Care Quality for Consumers Information on health care quality is complicated, so it’s crucial to present this information as simply and clearly as possible. This section suggests ways to make the language in your printed or Web-based quality report cards easier for your inten…

8632. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34783/psn-pdf
      March 28, 2005 - The organizational and intraorganizational development of disasters. March 28, 2005 Turner BA. The Organizational and Interorganizational Development of Disasters. Adm Sci Q. 1976;21(3):378. doi:10.2307/2391850. https://psnet.ahrq.gov/issue/organizational-and-intraorganizational-development-disasters This article…

8633. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47469/psn-pdf
      October 17, 2018 - Making doctors better. October 17, 2018 Gerada C, Chatfield C, Rimmer A, et al. Making doctors better. BMJ. 2018;363:k4147. doi:10.1136/bmj.k4147. https://psnet.ahrq.gov/issue/making-doctors-better Systems must be designed to support staff well-being and safety. This commentary introduces an ongoing collection of…

8634. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
      August 01, 2009 - Is that an important difference between health care and industry in trying to create a culture that will … methods for accomplishing work blocked by dysfunctional processes.( 7 , 8 ) Health care has a workaround culture … expertise in overcoming obstacles to get the job done.( 8 , 9 ) Workarounds are part of health care's culture … What can organizations do to move from a workaround culture to a culture that uses operational failures

8635. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer | PSNet
      psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
      February 26, 2025 - In fact, the success of the ASN has instilled a culture of innovation within the local hospital system … Establish a just culture framework and ensure buy-in from all partners. … Engage just culture principles and transform thinking from a root-cause analysis framework to a systems-focused

8636. Meeting Minutes, April 2019 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2019-04-nac/nacmtg0419-minutes.html
      July 01, 2019 - Masica raised the idea of professional culture changes as they relate to diagnostic error. Dr. … Brady noted that AHRQ has considered that area and has added supplemental items in its patient safety culture … How does culture become different? How is it assessed?

8637. Appendix V. JAMIA Draft Manuscript | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ssi/ssiapv.html
      April 01, 2018 - Culture Type Map to Procedure Types Appendix F. Algorithms Appendix G. … We then investigated the relationship of leukocyte count, temperature, the sending of a culture, the … For the algorithm, we used whether a culture was sent from a site consistent with SSI. … any high-normal laboratory value, as well as a "simple" algorithm that looked only for post-operative cultures … that patients with either deep or organ-space SSI would be absent of both antibiotic therapy and any culture

8638. Health Information Technology to Support Clinical Decision Making in Obesity Care - 2012 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/health-information-technology-support-clinical-decision-making-obesity-care/annual-summary/2012
      January 01, 2012 - Health Information Technology to Support Clinical Decision Making in Obesity Care - 2012 Project Name Health Information Technology to Support Clinical Decision Making in Obesity Care Principal Investigator Gance-Cleveland, Bonnie Organization Arizona State University - Tempe…

8639. Health Information Technology to Support Clinical Decision Making in Obesity Care - 2011 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/health-information-technology-support-clinical-decision-making-obesity-care/annual-summary/2011
      January 01, 2011 - Health Information Technology to Support Clinical Decision Making in Obesity Care - 2011 Project Name Health Information Technology to Support Clinical Decision Making in Obesity Care Principal Investigator Gance-Cleveland, Bonnie Organization Arizona State University - Tempe…

8640. Systematic Review | Digital Healthcare Research
      digital.ahrq.gov/research-method/systematic-review
      January 01, 2024 - Systematic Review Predicting suicide attempts among people with diabetes using a large multicenter electronic health records dataset. Citation Narindrarangkura P, Alafaireet PE, Khan U, Kim MS. Predicting suicide attempts among people with diabetes using a large multicenter e…