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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - activities and the determination to achieve consistently safe operations a blame-free environment where individuals … A just culture focuses on identifying and addressing systems issues that lead individuals to engage
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psnet.ahrq.gov/node/33701/psn-pdf
October 01, 2010 - A checklist can
help support individuals operating in such automatic environments by signaling that … For example, in
a cockpit, the checklist may only address the actions of pilot and co-pilot—individuals … A crucial component of checklist design is to allocate tasks to individuals.(13)
This prevents diffusion
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psnet.ahrq.gov/node/49641/psn-pdf
November 01, 2011 - patients for HBV prior to
cancer chemotherapy, especially patients at high risk.(1-4) This includes all individuals … Groups at high risk of HBV who should be screened (from AASLD guidelines [1])
Individuals born in areas … history of sexually transmitted disease
Men who have sex with men
Inmates of correctional facilities
Individuals
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - Organizations and individuals are increasingly embracing the use of video for learning. … Structured, routine post-action reviews, either by individuals or by teams, are also becoming more
prevalent … S1072751508014567#appd001
https://psnet.ahrq.gov//#ref15
https://psnet.ahrq.gov//#ref3
become available, individuals
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psnet.ahrq.gov/node/49718/psn-pdf
January 01, 2015 - creatinine level to estimate
kidney function, there is a substantial misclassification, particularly in individuals … , is a more accurate estimation of
kidney impairment, but still overestimates renal function among individuals … have not been widely studied.(8) Nonetheless, principles and guidelines for
K+ repletion do exist for individuals
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psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - Leaders will need to establish a
fertile environment for such individuals by ensuring that PS/QI efforts … They can also help ensure a
positive safety climate, one in which individuals are not blamed for innocent … Don't Take a Temperature"
Changing a culture ultimately requires changing the hearts and minds of individuals
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psnet.ahrq.gov/node/49601/psn-pdf
April 01, 2010 - Most severe nose bleeds of this nature
occur in individuals older than 50 years.(1)
https://psnet.ahrq.gov … Neoplasm is a rare cause but should be considered in individuals with recurring bleeds
from the same … Posterior bleeds
are more commonly seen in older individuals, and their management is more complex,
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psnet.ahrq.gov/web-mm/outbreak
January 29, 2015 - Pathogens can be transmitted through direct contact with infected individuals or contaminated objects … standard, airborne, and contact precautions.( 7,10 ) A vaccine is available and effective for high-risk individuals … , though pre-exposure vaccination is not currently recommended for individuals who do not work directly
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
March 01, 2014 - and feedback is facilitated by a safety culture in which continuous learning is kept front and center
Individuals … professionals
Organizations should build processes for assessing the extent to which systems and/or individuals … caseID=273.
21
Systems and Accountability
Balancing systems and individuals' accountability is critical
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-0
September 27, 2017 - September 18, 2019
The rise of human factors: optimising performance of individuals and
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psnet.ahrq.gov/issue/cognitive-factors-health-care
November 19, 2014 - September 18, 2019
The rise of human factors: optimising performance of individuals and
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psnet.ahrq.gov/issue/when-doctors-make-mistakes-1
May 01, 2013 - July 31, 2019
The rise of human factors: optimising performance of individuals and teams
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - Although relatively uncommon, obstetric emergencies still affect thousands of individuals and can have … The University of Kansas Hospital offered the course five times per year, with roughly 50 individuals … He then administered the course to these individuals and held several rehearsals. … After this trial, the labor and delivery department scheduled all involved individuals (approximately … Adjusting schedule: Because training all individuals during the same week proved logistically difficult
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - serious injuries, 1 such as fractures or head trauma, falls can have important psychological impacts on individuals … For both individuals, an interdisciplinary person-centered care plan for fall prevention would be appropriate … Vitamin D supplements to prevent falls in NH, although there are recommendations for community dwelling individuals … effect of opioids on the central nervous system, increasing fall risk. 17 Likewise, particularly for individuals … expectations include: (1) successful performance of the activity; (2) verbal encouragement; (3) seeing like individuals
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psnet.ahrq.gov/submit-innovations-landing
February 26, 2025 - Home
Improvement Resources
Innovations
Innovation Submissions
Individuals
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - power—revealed that catastrophic safety failures are almost never caused by isolated errors committed by individuals … In this model, errors made by individuals result in disastrous consequences due to flawed systems—the … used in health care, emphasizes that most errors result from system flaws but also delineates where individuals
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - of telehealth services can eliminate the need for travel to a primary care facility, and may benefit individuals … Integrating Primary Care into Behavioral Health Settings: What Works for Individuals with Serious Mental … most impactful model would be to have community health workers develop long-term relationships with individuals … In addition, community health workers supported individuals with behavior changes that would help them … We spoke with him about the role of primary care in the health and well-being of individuals, the hallmarks
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psnet.ahrq.gov/issue/safety-competencies-framework
October 25, 2017 - Quality
April 26, 2023
The rise of human factors: optimising performance of individuals
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psnet.ahrq.gov/issue/annual-benchmarking-report-malpractice-risks-surgery
July 18, 2018 - Endorsements of surgeon punishment and patient compensation in rested and sleep-restricted individuals
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psnet.ahrq.gov/issue/quality-anesthesia-care
March 27, 2005 - September 18, 2019
The rise of human factors: optimising performance of individuals and