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1321. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33689/psn-pdf
      October 01, 2009 - understood that health care could cause harm, this concern was too inchoate to generate real change in the culture … It cannot just be frequency: the heparin dosing error experienced by the Quaid twins has happened hundreds … Just as the physician signing the surgical site, the nurse cleaning her hands, the quality manager developing

1322. 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.

1323. The "Customer" Is Always Right | PSNet
      psnet.ahrq.gov/web-mm/customer-always-right
      January 22, 2014 - After discussion and counseling, the patient responds with, "I'm reassured that you think my ankle is just … 2014 Enculturation of unsafe attitudes and behaviors: student perceptions of safety culture … July 2, 2014 AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses.

1324. Managing Ascites: Hazards of Fluid Removal | PSNet
      psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
      June 01, 2018 - The case prompted a formal review since the entire hospitalization was deemed preventable given the belief … Therefore, the threshold for performing a diagnostic paracentesis and sending the fluid for culture should … receive a thorough evaluation for other evidence of systemic infection, including a urinalysis, blood cultures … I would regard it as potentially predictable and just treat the complication as needed.

1325. Patient and Family Roles in Safety | PSNet
      psnet.ahrq.gov/perspective/patient-and-family-roles-safety
      June 14, 2023 - My work, beliefs, and commitment have been shaped by early life experiences. … These partnerships need to be foundational to the culture of the organization. … That type of list just makes so much sense. … Hospitals are beginning to change the concept of families as “visitors,” returning to the belief that … Some places just shut down their PFACs.

1326. Safety I, Safety II, and the New Views of Safety | PSNet
      psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
      October 02, 2024 - and on Normal Accidents and HROs 1990s and on Swiss Cheese and Safety Management 2000s and on Safety Culture … viewed, as well as the utility of the concept of human error. 1 , 13-15 This questioning of long held beliefs … enables the incorrect assumption that observations in this limited subset of cases demonstrate not just … Hollnagel terms this the causality credo , which he defines as “the belief that adverse outcomes happen … and early adoption. 23 Work as Done and Work as Imagined “Work-as-Done” and “Work-as-Imagined” are just

1327. Innovations in Promoting Hand Hygiene Compliance | PSNet
      psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
      May 01, 2014 - Whether to build in incentives or just use pride and shame and some level of public reporting? … According to your institutional level of hand hygiene culture, you may be pushed today to make sure that … You will realize that from performance monitoring, that education and institutional safety culture have … An important point is to realize that we need to adapt this strategy to different cultures and different … Sometimes people look at hand hygiene and say, it should just be required.

1328. In Conversation With… Maureen Bisognano | PSNet
      psnet.ahrq.gov/perspective/conversation-maureen-bisognano
      February 26, 2025 - Let me just give you a couple of examples of the new way we're thinking at IHI about safety. … burnout, particularly people feeling like they have been working very hard at these things and it's just … MB : To me good leadership understands the difference between the two circumstances you just described … In other words, the culture and context matter, the leaders matter, and the mechanism is the change concept—it's … Hence, the theory was that if you understood your culture and you had a mechanism that you could try

1329. What Does Simulation Add to Teamwork Training? | PSNet
      psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
      October 01, 2004 - any chance of developing new and optimal teamwork patterns that become deeply ingrained in the work culture … is very important that participants have a chance to actually "deploy" the skills being taught, not just … June 16, 2011 How does patient safety culture in the operating room and post-anesthesia … Providers Health Care Executives and Administrators Educators Communication between Providers Culture

1330. Risk Management and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/risk-management-and-patient-safety
      December 01, 2010 - I think we have a whole group of physicians who grew up with that belief system and who trained the next … generation in that belief system. … Disclosure is also a skill for life, not a skill just for work. … I don't think it had anything to do with the places as much as the individual cultures of those hospitals … So families have an important role, but if I can be intimidated with what I know and my beliefs about

1331. In Conversation With… Charles Vincent, MPhil, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
      July 10, 2024 - That's one of the strengths if you're running an aviation reporting system and you're just trying to … It's a familiar safety story, but that was just one of those things that has now become unacceptable. … The clinicians can just get on the phone and say, "There's something very odd happening here," or, "I … But, ours just mushroomed and in a way tried to take on—or was pushed into—trying to do things that the … It's a little better now, but if you and I were just trying to decide how much of the patient safety

1332. Artificial Intelligence and Patient Safety: Promise and Challenges | PSNet
      psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
      March 27, 2024 - In some cases, just taking that second look at a problem with this set of AI-fueled lenses leads us to … First, we have a patient who is hypotensive, tachycardic with fever, and positive blood cultures immediately … It really humbled us and made us realize that just being able to predict an outcome is not the same as … It’s not just what we did, it’s the how we care for somebody. … Annual Perspective Ensuring Patient and Workforce Safety Culture

1333. The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis | PSNet
      psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
      February 26, 2025 - Just over a week after the identification of the first safety incidents, the team disseminated the … To support implementation , unit leaders provided just-in-time training, ICU dashboards facilitated … committees Dissemination channels online, via standing conferences, and through regular meetings A culture

1334. In Conversation with…Barbara A. Blakeney, MS, RN | PSNet
      psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
      August 01, 2005 - Is it that there's not enough money, or that the culture is not one that promotes recruiting and retaining … We just believe that the people who are best able to determine what each unit needs are those who are … Finally, we need a culture in which safety is considered a problem-solving situation and not a punishment … of the American Nurses Credentialing Center is the best example of a successful blueprint to guide culture … April 9, 2008 Navigating the perfect storm: balancing a culture of safety with workforce

1335. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49734/psn-pdf
      May 01, 2015 - Just then, another trauma patient arrived, and the supervising attending physician left the room. … Here, the safety culture of the operating room (OR) provides us some ideas. … simulation training, these extra eyes may safely be borrowed from the nursing staff—assuming that a culture

1336. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49798/psn-pdf
      July 01, 2017 - ACPO should be suspected in patients who have acute illness or have just had surgery who develop abdominal … A gastroenterologist who had just finished her fellowship training performed a decompression colonoscopy … It is unclear if the gastroenterologist, who had just recently completed her training, was experienced … An institutional culture that encourages communication among all members of the health care team can

1337. Patient Safety Amid Nursing Workforce Challenges | PSNet
      psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
      April 24, 2024 - assemble the Nurse Staffing Think Tank, a diverse group of stakeholders from around the country—not just … It’s not just the hourly rate, but health systems must also pay a stipend, in some cases upfront, to … It’s key to create a culture where everyone is welcome. We all depend on each other. … Instilling a culture that says, “We’re all a team, no matter who’s here,” is the way to move forward. … We can’t just leapfrog over those who are delivering care and then say we care about patient care.

1338. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73905/psn-pdf
      October 06, 2021 - In many ways, this viewpoint may be just as important to patients when it comes to defining safe maternal … The goals of this work are to advance just, effective perinatal care by identifying underlying factors

1339. In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
      August 01, 2016 - We are aware that the information we have is just a small part of the total. … diagnostic terms.( 19 ) Clearly, though, the greatest hurdle is to establish a robust patient safety culture … in the dental ecosystem.( 20 ) As challenging as it has been to establish a safety culture in medicine … Is ambulatory patient safety just like hospital safety, only without the "stat"? … Open wide: looking into the safety culture of dental school clinics. J Dent Educ. 2014;78:745-756.

1340. How Does Health Care Simulation Affect Patient Care? | PSNet
      psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
      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.