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1361. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49823/psn-pdf
      March 01, 2018 - Although limited data exist, the prevailing culture of medicine is toward nonintervention during pregnancy … interventions in pregnancy is laudable, medical or surgical risks need to be balanced against not just … simulation training, morbidity and mortality reviews, critical thinking training, and an organizational culture

1362. A Mid-Summer Fog | PSNet
      psnet.ahrq.gov/web-mm/mid-summer-fog
      September 29, 2017 - second-year colleagues during their early days or reviewing all or a sample of orders by new interns are just … Related Resources From the Same Author(s) Development of a high-value care culture … April 24, 2014 A leadership framework for culture change in health care.

1363. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33717/psn-pdf
      September 01, 2011 - electronic reporting interfaces, excluding reported information from performance reviews, improving safety culture … directors.(1) Anecdotally, hospitals with particularly strong commitments to safety use reporting as just … The senior leadership defines what the safety culture should look like, seeks out new safety technologies

1364. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49737/psn-pdf
      June 01, 2015 - Just prior to insertion of the catheter by a registered nurse (RN), the patient voided but the amount … Since the patient had just voided, the RN assumed the patient's bladder was empty. … focused competency-based approach to review the microbiology of CAUTI, urinalysis collection, and urine culture … As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily

1365. Making Healthcare Safer III Report | PSNet
      psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
      March 30, 2020 - The included cross-cutting topics/practices are: improving safety culture; teamwork and team training … 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

1366. Human Factors Engineering | PSNet
      psnet.ahrq.gov/primer/human-factors-engineering
      December 15, 2024 - Cause Analysis June 15, 2024 Alert Fatigue December 15, 2024 Editor's Picks Just … October 4, 2017 Changing our culture: adopting the military aviation safety system.

1367. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73153/psn-pdf
      April 28, 2021 - 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

1368. In Conversation With… Michelle Mello, MPhil, JD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
      July 01, 2017 - are counterproductive and that beg the question of how we can make law work better for medicine—not just … But we ask them to do so in the context of a system that has shifted the standard of care from just imposing … unsurprising given the number of legislators who are lawyers themselves and who are steeped in the culture … It is a massive culture shift for institutions to move from a traditional "deny-and-defend" posture to … a culture in which not only do health care providers feel supported in disclosing error, but the insurance

1369. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? | PSNet
      psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
      July 01, 2017 - are counterproductive and that beg the question of how we can make law work better for medicine—not just … But we ask them to do so in the context of a system that has shifted the standard of care from just imposing … unsurprising given the number of legislators who are lawyers themselves and who are steeped in the culture … It is a massive culture shift for institutions to move from a traditional "deny-and-defend" posture to … a culture in which not only do health care providers feel supported in disclosing error, but the insurance

1370. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60329/psn-pdf
      May 14, 2020 - Joel Willis: This is Joel Willis and I am a family medicine trained physician and I just completed residency … So it’s not that you are working to establish GW’s infrastructure, you are just using it in new and … stroke telemedicine in much the same way they would from outside the hospital, but in this case from just … NS: Just last night we were recording a video showing how a clinician can walk a patient through an … I think you should have a quality assurance plan as well, just like we have M&M [morbidity & mortality

1371. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49819/psn-pdf
      February 01, 2018 - to teach faculty supervisors the I-PASS Method and to do assessment observations; A process- and culture-change … Because handoff processes become entrenched in institutional culture, efforts to improve them require … more than just training, assessment, and feedback.

1372. Health Care Delivery and Pharmacists During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
      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.

1373. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852700/psn-pdf
      August 30, 2023 - We’ve seen setbacks in safety culture scores, engagement, and feeling valued, as well as  attrition … It’s about ensuring that the work environment, cultures of safety and equity, safety systems, competencies … The first foundational area is culture, leadership, and governance—ensuring that there is a core value … support and reflect healthcare workers’ workflow, and the conditions in which they work, and people are just … This means that if organizations focus only on one foundational area, such as culture, leadership, and

1374. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49588/psn-pdf
      August 01, 2009 - Since the patient with COPD just admitted appeared to be improving rapidly, and the other nurses were … The solutions are multifaceted, and all solutions begin with the nursing culture of the organization … This commentary has expressed both proactive and just-in-time approaches to making patients safe.

1375. In Conversation with...Mark Chassin, MD, MPP, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
      April 01, 2009 - RW: Do you have any sympathy for the hospital that says, "We just can't afford to continue to do this … The challenge for hospitals is to develop ways to credential physicians that meet not just The Joint … If you think back just 10 years ago, when hospitals were not measuring anything on any sort of national … It is not surprising, therefore, to find a certain tension between the culture of medicine and the demands

1376. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836850/psn-pdf
      March 31, 2022 - The report recommended transitioning to a “Just Culture” in nursing school programs. … nurses-perceived-causes-medication-administration-errors-qualitative-systematic-review https://psnet.ahrq.gov/issue/just-culture-medication-error-prevention-and-second-victim-support-better-prescription

1377. Wandering Off the Floors: Safety and Security Risks of Patient Wandering | PSNet
      psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
      August 21, 2007 - Especially in patients with prolonged hospitalizations, there often is just a need to "get some fresh … Suction Tip November 1, 2003 Association of diagnostic stewardship for blood cultures … in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the

1378. Lost in Transition | PSNet
      psnet.ahrq.gov/web-mm/lost-transition
      November 17, 2010 - The outgoing ED physician had just completed the shift and signed the patient out to the oncoming colleague … time-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.

1379. Patient Safety in Home Dialysis | PSNet
      psnet.ahrq.gov/perspective/patient-safety-home-dialysis
      April 28, 2021 - it comes to some more involved therapies, it really allows for more sustainability than relying on just … I think that you’ve answered just about all of our questions. … away, and I think when we are looking at treatment options, we have to know that there is more than just … JAM : I just want to thank you for taking time and for taking interest in this program. … Resources From the Same Author(s) Perspectives on Safety Safety Culture

1380. In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
      May 14, 2020 - Joel Willis: This is Joel Willis and I am a family medicine trained physician and I just completed residency … stroke telemedicine in much the same way they would from outside the hospital, but in this case from just … NS : Just last night we were recording a video showing how a clinician can walk a patient through an … I think you should have a quality assurance plan as well, just like we have M&M [morbidity & mortality … It is important for institutions to maintain good patient safety culture and ensure that providers have