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441. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? | PSNet
     psnet.ahrq.gov/issue/mortality-and-morbidity-meetings-untapped-resource-improving-governance-patient-safety
     June 25, 2014 - Adoption of a standardized process can reduce variation in the way deaths are reviewed and foster a culture … December 29, 2014 The role of organizational and professional cultures in medication … December 19, 2014 'I think we should just listen and get out': a qualitative exploration … July 1, 2013 Impact of organizational culture on preventability assessment of selected

442. Safety of the Manchester Triage System to detect critically ill children at the emergency department. | PSNet
     psnet.ahrq.gov/issue/safety-manchester-triage-system-detect-critically-ill-children-emergency-department
     October 18, 2023 - April 5, 2017 Fostering a just culture in healthcare organizations: experiences in practice … August 31, 2022 Role of the regulator in enabling a just culture: a qualitative study

443. "You just want to feel safe when you go to a healthcare professional:" intimate partner violence and patient safety. | PSNet
     psnet.ahrq.gov/issue/you-just-want-feel-safe-when-you-go-healthcare-professional-intimate-partner-violence-and
     January 27, 2019 - Study "You just want to feel safe when you go to a healthcare professional:" intimate … “You just want to feel safe when you go to a healthcare professional:” Intimate partner violence and … “You just want to feel safe when you go to a healthcare professional:” Intimate partner violence and … May 11, 2022 The relationship between safety culture and voluntary event reporting in

444. Just-in-time training for high-risk low-volume therapies: an approach to ensure patient safety. | PSNet
     psnet.ahrq.gov/issue/just-time-training-high-risk-low-volume-therapies-approach-ensure-patient-safety
     April 24, 2018 - Commentary Just-in-time training for high-risk low-volume therapies: an approach … Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety. … Just-in-Time Training for High-Risk Low-Volume Therapies: An Approach to Ensure Patient Safety. … April 13, 2017 Changing the "working while sick" culture.

445. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
     March 01, 2007 - An ethical dilemma: medical errors and medical culture. BMJ. 2001;322:1236-1240. … Perception that management would take no notice and was not likely to do anything about the problem Belief … confidential incident reporting system Use reports to identify common error producing factors, not to just … physicians and staff about the importance of learning from mistakes Success attributed to reinforcement of “just … culture” and visible improvements resulting from reported incidents See Notes for references. 21.

446. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33720/psn-pdf
     November 01, 2011 - resources and incentive, as much as you can, to facilitate these behaviors on the job, as well as a culture … So in the end, it's the culture that sustains the training. … And it's all about the culture of the organization, what leadership does. … Similar to the way the culture of the aviation industry has evolved, which has taken 20 years to change … , changing the culture of the health care industry will require a new generation of doctors that are

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39381/psn-pdf
     March 17, 2010 - getting-it-right-when-things-go-wrong This brief commentary discusses the relationship between blame, accountability, and just … culture, as well as support for clinicians involved in errors.

448. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866847/psn-pdf
     September 25, 2024 - You just spoke to the fact that harm does happen even in organizations that have a zero-harm goal. … Safety as the core value means that the commitment to zero harm is not just some of the time, but all … Zero harm and safety culture go hand-in-hand, an uncompromising commitment to safety as a core value … Sarah Mossburg: So having that safety culture and leader’s support of safety culture in what they say … Sarah Mossburg: You mentioned the importance of a culture of safety and organizational context, which

449. Omissions of care in nursing homes: a uniform definition for research and quality improvement. | PSNet
     psnet.ahrq.gov/issue/omissions-care-nursing-homes-uniform-definition-research-and-quality-improvement
     August 01, 2012 - April 28, 2021 Integrating principles of safety culture and just culture into nursing … January 12, 2022 Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2024 … February 28, 2024 Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center … 8, 2023 View More Related Resources Surveys on Patient Safety Culture

450. Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders' perceptions of elder abuse and neglect. | PSNet
     psnet.ahrq.gov/issue/elder-abuse-and-neglect-overlooked-patient-safety-issue-focus-group-study-nursing-home
     March 20, 2019 - February 15, 2023 Nursing home patient safety culture perceptions among licensed practical … February 1, 2023 Patient safety culture in assisted living: staff perceptions and association … June 8, 2022 Integrating principles of safety culture and just culture into nursing homes … January 12, 2022 Differences between professionals' views on patient safety culture in … August 4, 2021 Nursing home staff turnover and perceived patient safety culture: results

451. The objective impact of clinical peer review on hospital quality and safety. | PSNet
     psnet.ahrq.gov/issue/objective-impact-clinical-peer-review-hospital-quality-and-safety
     April 13, 2017 - November 28, 2018 An assessment of the impact of just culture on quality and safety in … View More Related Resources Professionalism: a necessary ingredient in a culture … Patient Safety Dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture … February 2, 2011 Assessing and improving safety culture throughout an academic medical

452. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33764/psn-pdf
     April 01, 2014 - I think we're just starting to get experience with this. … TG: This is an area that we're just starting to explore. … Recently we called Brian Sexton who had done pioneering work on safety culture. … the culture of punishment and blame. … RW: I'm finding that even in environments where the culture seems pretty good, there's a reasonable

453. In Conversation With… Tejal K. Gandhi, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
     February 26, 2025 - I think we're just starting to get experience with this. … TG : This is an area that we're just starting to explore. … Recently we called Brian Sexton who had done pioneering work on safety culture. … We had spoken with him 6 or 7 years ago about what we're learning about teamwork training and culture … the culture of punishment and blame.

454. Action needed to prevent dangerous heparin-insulin confusion. | PSNet
     psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion
     May 07, 2018 - July 17, 2018 Just Culture and its critical link to patient safety—part 1 and part 2. … May 3, 2023 Administering just the diluent or one of two vaccine components leaves patients

455. Lesson from the VA's Team Training Program | PSNet
     psnet.ahrq.gov/perspective/lesson-vas-team-training-program
     November 01, 2011 - culture," and improving patient safety.( 18 ) The success of MTT programs will depend on engagement … Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability … But a lot of hospitals call me for what you just asked me. … So in the end, it's the culture that sustains the training. … And it's all about the culture of the organization, what leadership does.

456. In Conversation With… Eduardo Salas, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
     November 01, 2011 - But a lot of hospitals call me for what you just asked me. … So in the end, it's the culture that sustains the training. … And it's all about the culture of the organization, what leadership does. … , changing the culture of the health care industry will require a new generation of doctors that are … Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49864/psn-pdf
     June 01, 2019 - Describe the role of leaders in establishing and maintaining a culture of safety. … examine the correct patient and found that large bilateral pleural effusions were indeed present, just … Leadership is important but insufficient to ensure a culture of speaking up. … Strategic decisions, supported by resources, must then follow this belief. … Is professionalism, respect, and just culture actively working?

458. Medication governance: preventing errors and promoting patient safety. | PSNet
     psnet.ahrq.gov/issue/medication-governance-preventing-errors-and-promoting-patient-safety
     November 08, 2023 - that weaken the medication administration process, this commentary highlights collaboration, safety culture … From the Same Author(s) Viewpoint: Patient safety in primary care - patients are not just … January 27, 2016 The Nurse's Role in Promoting a Culture of Patient Safety. … February 4, 2015 Creating a culture of safety by coaching clinicians to competence.

459. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42293/psn-pdf
     January 01, 2015 - leadership-and-patient-safety-review-literature This narrative review highlights elements of work environments and leadership, including just … culture and shared decision making, that contribute to patient safety.

460. Consumers Advancing Patient Safety. | PSNet
     psnet.ahrq.gov/issue/consumers-advancing-patient-safety
     January 20, 2016 - CAPS envisions a health care system that is safe, compassionate, and just. … August 20, 2018 The Challenger Launch Decision: Risky Technology, Culture, and Deviance … View More See More About The Topic Quality and Safety Professionals Patients Culture