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1341. The Dangerous Detour | PSNet
      psnet.ahrq.gov/web-mm/dangerous-detour
      November 28, 2018 - We also propose that, just as signs such as “Fall Risk” or “Seizure Precautions” are posted in and outside … Suicidality should be assessed regularly, as a vital sign , in such patients, just as pain assessment

1342. In Conversation With… Edward Kelley, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
      December 01, 2014 - Or is this higher on Maslow's triangle, in that they're just not ready for it yet? … You have that times 200 given all the countries and variations in resources and culture and history. … To just give an example from one of our close colleagues, Peter Pronovost , WHO has a special Patient … I just saw an excellent presentation from Estonia about patients having access to their own radiology … It's just not going to happen, or not going to happen easily.

1343. In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
      March 30, 2020 - The new cross-cutting topics, such as Safety Culture, Teamwork and Communication, etc. also help to highlight … Just putting sepsis early detection systems in your EHR doesn’t necessarily save lives. … This is something that we are just starting to get our arms around, and we should spend more time on … The included cross-cutting topics/practices are: improving safety culture; teamwork and team training

1344. Long-Term Care and the Response to COVID-19 | PSNet
      psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19
      October 28, 2020 - LP : Not just comparisons between providers, but also between facilities. … KH : Let’s talk about the culture in these nursing homes. … You just learn to deal with it. … LP : This actually leads on nicely from what we were just talking about. … People just didn’t want to go there.  

1345. In Conversation With... Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN | PSNet
      psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
      October 28, 2020 - LP : Not just comparisons between providers, but also between facilities. … KH : Let’s talk about the culture in these nursing homes. … You just learn to deal with it. … LP : This actually leads on nicely from what we were just talking about. … People just didn’t want to go there.  

1346. African Partnerships for Patient Safety: Lessons Learned | PSNet
      psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
      December 01, 2014 - stood in the vast hall in Yaoundé, Cameroon, listening to the proceedings—admittedly a little nervous just … Or is this higher on Maslow's triangle, in that they're just not ready for it yet? … You have that times 200 given all the countries and variations in resources and culture and history. … I just saw an excellent presentation from Estonia about patients having access to their own radiology … It's just not going to happen, or not going to happen easily.

1347. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846125/psn-pdf
      March 15, 2023 - i-readi-quality-and-safety-framework-strong-communications-channels-and-effective https://psnet.ahrq.gov//#1 Just … To support implementation, unit leaders provided just-in-time training, ICU dashboards facilitated a … committees Dissemination channels online, via standing conferences, and through regular meetings A culture

1348. Rethinking Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
      August 21, 2016 - Taking an overly algorithmic approach to just culture can obscure complicated relationships between individual … name emphasizes that the outcomes of the RCA—the corrective actions and resultant risk mitigation—are just

1349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33698/psn-pdf
      August 01, 2010 - Once you ingrain the process as a culture, I think it is sustainable. … exists in Pennsylvania, Penn's desire to really try to be great in this domain, and my commitment and belief … When you begin to codify them, it's just staggering.

1350. Hyperglycemia and Switching to Subcutaneous Insulin | PSNet
      psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
      May 19, 2021 - organizations can use to prevent these errors include teamwork training and efforts to improve the culture … An organizational culture of safety promotes teamwork and standard practice using the Glucommander and … assess glycemic control and monitor the processes that support good outcomes, including those related to culture … Glucommander use Lack of an institutional standard of care for inpatient glycemic control Routine and just-in-time

1351. How Do Providers Recover From Errors? | PSNet
      psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
      May 22, 2024 - The resident then realized that the effusion was on the contralateral side, not the left side she had just … conferences at many institutions.( 10,14,20,21 ) These conferences historically have been extensions of the culture … A culture shift will be necessary to create a productive process for the provider sharing the medical … New culture for coping: turning to peer support after medical errors. American Medical News.

1352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49552/psn-pdf
      January 01, 2008 - resident then realized that the effusion was on the contralateral side, not the left side she had just … conferences at many institutions.(10,14,20,21) These conferences historically have been extensions of the culture … A culture shift will be necessary to create a productive process for the provider sharing the medical … New culture for coping: turning to peer support after medical errors. American Medical News.

1353. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33693/psn-pdf
      February 01, 2010 - They also recommended improvements to the culture of safety through error detection, reporting, and … communication is now a required element for accreditation for all hospitals.(23) Collaborations with Others Just … Medical schools have begun to directly assess all six competencies, rather than just knowledge and patient

1354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49501/psn-pdf
      February 03, 2006 - The outgoing ED physician had just completed the shift and signed the patient out to the oncoming colleague … dependent outcomes invariably rely on many individual processes and interactions; the transition phase is just … Culture and high reliability organizations: the case of the nuclear submarine. J Manage.

1355. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet
      psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
      September 01, 2003 - The physician came by to see the patient just before discharge and asked the patient, using the patient … The hospital’s culture should support nurses to raise scope of practice questions when they are asked … Organizational culture should encourage health care providers to communicate and collaborate with each

1356. In Conversation With... Anna Legreid Dopp, Pharm. D | PSNet
      psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
      June 29, 2020 - Just linking back to what I said previously, it’s all thanks to hearing from those members that are on … I credit the culture shift over the last 20 years to make sure that patient safety remains front and … Has that changed at all or are we just doing it differently? … We’re really pleased that we are able to open up all of these resources, not just for our members but … On that website, there is a page dedicated just for patients related to COVID-19.

1357. Innovations | PSNet
      psnet.ahrq.gov/innovations
      February 26, 2025 - Structured Hand-offs (6) Provider-Patient Communication (12) Culture … of Safety (8) Just Culture (1) Learning Organization (1)

1358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33814/psn-pdf
      September 01, 2016 - Let me just first say that you are making an observation of how medical care is being practiced today … However, the level of physician participation and leadership in telehealth encourages me, just as we … But it just can't work that way. … diastolic numbers into the physician's office so they can be tracking you instantaneously—it would just

1359. In Conversation with...Bradley T. Rosen, MD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
      March 01, 2008 - Over time, this was not just a service provided to teaching physicians, but private physicians who also … The outpatients have really just evolved as a bonus. … lines if a line is in place and there is a concern about a low-grade fever, or one out of four blood cultures … This is just my opinion, but I think if you drop down below 50% of your time doing procedures, you're … in, or the vessels are just too tiny or thrombosed that they need assistance with.

1360. Creation of a Medical Procedure Service to Improve Patient Safety | PSNet
      psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
      March 01, 2008 - The outpatients have really just evolved as a bonus. … lines if a line is in place and there is a concern about a low-grade fever, or one out of four blood cultures … This is just my opinion, but I think if you drop down below 50% of your time doing procedures, you're … But there are patients who are wildly coagulopathic that the team just doesn't want to stick a needle … in, or the vessels are just too tiny or thrombosed that they need assistance with.