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1301. Security Lapse | PSNet
      psnet.ahrq.gov/web-mm/security-lapse
      December 18, 2019 - Rather, just as medical errors have complicated causes, HIPAA is a complex medico-legal matter, which … Indeed, reporting errors is one of the few ways that my classmates, often just onlookers, have actually … On the culture of student abuse in medical school.

1302. In Conversation With… Matthew Weinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
      August 01, 2018 - MW : It's probably both, but I think there just is not a lot of money in health care education. … Some other countries do more simulation, but there's a fundamental cultural belief that's still hard … Contrast that with nuclear power, where a safety culture is imposed in part by the regulators and in … Two other advances that we're just beginning to see are going to be really exciting. … We're just starting to see this technology.

1303. In Conversation with… Edward Tenner, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
      June 01, 2011 - Editor's note: Edward Tenner is an independent writer, speaker, and consultant on technology and culture … that is that organizations can start to deviate from established procedures and bend them if in their culture … The culture created at the top is more important than any number of experts that you have there. … Japan's culture made it harder to discuss the risk. … Here are just a few examples.

1304. Assessing the Safety of Electronic Health Records: What Have We Learned? | PSNet
      psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
      September 01, 2017 - The best approach to both understanding and resolving them is sociotechnical, which includes not just … planning for downtime and system configuration).( 16 ) Lesson Two: EHR Safety Requires More Than Just … As such, another key facet of this work is for organizational leadership to create the blame-free culture … When you ask people why they don't just turn off those "this could happen" alerts, there's a concern … I routinely interact with not just the leadership of ONC but all the various staff members.

1305. Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula | PSNet
      psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
      February 01, 2019 - We have learned that creating such a transparent and just culture does not automatically result from … The larger health care system and culture must embrace and contribute to this shift for sustainable success … Only then will we achieve the level of transformation to create a culture of safety and to improve patient … Ensure that leaders establish and sustain a safety culture 2. … April 4, 2018 Changing the "working while sick" culture.

1306. Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective | PSNet
      psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
      June 01, 2016 - It wasn't just the notion that culture has an impact on safety, but that it could be quantified or measured … Just focusing on joy and meaning without really looking at culture and leadership is also going to be … And that's not just physicians; the same is true of nursing. … The truth is that today we're getting more cross-fertilization, not just at the university level but … Just like we see in other fields, we're going to have individuals who are working in the area who are

1307. Are Residency Duty Hour Rules Improving Patient Safety? | PSNet
      psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
      April 01, 2013 - This means that the local context (not just the schedules but the quality of the residents, the culture … of the program, the availability of effective information technology, and more) may be just as important … Do certain schedules, or other matters of culture, information technology, and leadership, lead to better … There is no way to enforce someone sleeping just because they are provided with time off work. … Just as we would expect our colleagues not to show up to work drunk, we should expect them to show up

1308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33700/psn-pdf
      October 01, 2010 - We just published in the BMJ that our Michigan results have now sustained for more than 3 years. … It was culture change on a couple of levels. … So we're okay questioning each other because we know it's just ensuring that we're doing what's right … We also ask them to tell us the strength of their belief that those actions will improve outcomes using … It's not going to happen just by encouraging people to do better.

1309. When it's surgery, don't get it wrong. | PSNet
      psnet.ahrq.gov/issue/when-its-surgery-dont-get-it-wrong
      August 18, 2010 - August 18, 2010 The safety culture in a children's hospital. … December 21, 2016 Care transitions know-how not just for clinicians. … November 21, 2016 When a surgeon should just say 'I'm sorry'.

1310. In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA | PSNet
      psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
      June 30, 2021 - COVID-19 is going to be just another scenario that we are going to have to look at when we do these … And it may not be just the hospital itself. … KH: With all this attention paid to sinks, surfaces, etc., now I'm just wondering has anybody been … Not just for COVID-19, there are so many applications. … Culture and Redesign. Agency for Healthcare Research and Quality; 2008.

1311. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843150/psn-pdf
      December 05, 2022 - a patient's name or pronouns because they do not want to enable something that goes against their beliefs … When it comes to healthcare though, their beliefs of normal shouldn’t interfere with someone’s ability … many people consider to be offensive because it suggests that you prescribe to a set of ideals or beliefs … , rather than this is just who you are.8 In these cases, healthcare is still very fallible. … We just want to be seen as humans, so that we can get our blood pressure managed on a regular basis.

1312. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33632/psn-pdf
      April 01, 2006 - RW: A lot of discussion in the patient safety world is about how to change the culture of physicians … But it's not just the financial rewards; I think there's great satisfaction in it. … I have personally seen a change, just in working with the committees that I'm on. … //patientsafety.pa.gov/pst/Pages/PSAPatientSafetyTopicList.aspx RW: These days, people talk about culture … I just was quiet, and he said, "We're talking about you."

1313. Difficult Encounters: A CMO and CNO Respond | PSNet
      psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
      March 01, 2018 - Describe characteristics of a culture that encourages open communication, respect, and opportunities … Organizations that aspire to create cultures of safety must address the pervasive behavioral patterns … Development of a culture such as this, however, requires more than role-modeling. … Just as the staff nurse needs to learn to speak up to defend patient safety, so too does the effective … Behaviors that undermine a culture of safety. Sentinel Event Alert. July 9, 2008.

1314. Psn-Pdf (pdf file)
      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 … My feeling was that this was just common sense. … 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

1315. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33608/psn-pdf
      February 01, 2024 - According to the Centers for Disease Control and Prevention (CDC), there were just over 3.6 million births … consistently safe access and equitable care, for all women regardless of systemic or provider unconscious belief … AHRQ’s Safety Program for Perinatal Care (SPPC) takes an overarching approach to improving safety culture … Just another ordinary bad birth? … Failure to rescue, communication, and safety Culture. Clin Obstet Gynecol. 2019;62(3):507-517.

1316. In Conversation With… Susan E. Skochelak, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
      February 01, 2019 - We have learned that creating such a transparent and just culture does not automatically result from … The larger health care system and culture must embrace and contribute to this shift for sustainable success … Only then will we achieve the level of transformation to create a culture of safety and to improve patient … PubMed] Table Institute for Healthcare Improvement Recommendations for a Systems Approach to a Culture … Ensure that leaders establish and sustain a safety culture 2.

1317. Topics | PSNet
      psnet.ahrq.gov/topics-0
      March 03, 2025 - to this topic Informed Consent Go to this topic Culture … Safety Go to this topic Institutional Patient Safety Plan Go to this topic Just … Culture Go to this topic Learning Organization Go to this topic Red Rules

1318. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
      December 23, 2020 - errors led to considerable soul searching and, ultimately, a major change in institutional practices and culture … We have adopted and promulgated model error disclosure practices and fair and just culture principles

1319. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46352/psn-pdf
      October 15, 2018 - Topics covered include high reliability, teamwork, communication, and patient-centered culture. … psnet.ahrq.gov/issue/optimal-resources-surgical-quality-and-safety https://psnet.ahrq.gov/issue/hospital-not-just-factory-complex-adaptive-system-implications-perioperative-care

1320. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33793/psn-pdf
      November 01, 2015 - We should have a no- blame culture. We should ban certain abbreviations. … Maybe it's just a slight inconvenience for some doctors. … I do wonder, even though I shied away from this 10 years ago, if culture, communication, and teamwork … One of my colleagues and I just wrote a piece about this too. … There's just too much, even on a weekly or biweekly basis.