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1001. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
      January 01, 2024 - Burden The burden of diagnostic errors exists beyond just health outcomes. … the detection of breakdowns in the diagnostic process.65 Conceptual models have been developed not just … to how culture, behavior, and work system influence diagnostic safety were limited. … was including search materials mostly since 2013 onward, so we missed certain key items published just … Improving test result follow-up through electronic health records requires more than just an alert.

1002. The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meyer_41.pdf
      March 03, 2008 - We chose just a few initial organization-wide adoption targets for our program to keep the organization … physicians were given the full financial reward ($500, $1,250, or $2,500 depending upon their wRVU tier) just … communications, (3) integrity r on 27 ut appropriate attention to our soil” (our organizational culture … Other components of that strategic planning included safety culture surveys, quality and safety leadership

1003. Final Progress Report: Improving Patient Safety: Health Systems Reporting, Analysis and Safety Improvement Research Demonstrations (pdf file)
      www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
      January 01, 2025 - The units were started at staggered times, and the pilot is just now ending, with the final few reports … survey addressing healthcare workers’ attitudes toward 1) medical errors in general, 2) the medical culture … Results Key Findings: Surveys are just beginning to be analyzed.

1004. 3. Defining Categorization Needs for Race and Ethnicity Data | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/iomracereport/reldata3.html
      May 01, 2018 - Coverage and Quality in Cancer Registries The American Indian or Alaska Native population makes up just … aggregation of data on cancer incidence, an especially important task because unique circumstances of culture … Categorizing Diverse Populations A wide range of cultures, languages, and health-related behaviors

1005. Final Progress Report: Caregiver innovations to reduce harm in Neonatal Intensive Care (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/thomas-report.pdf
      January 01, 2025 - participants associated with the NICU and Parent Advisory Council (PAC) to examine perceptions, attitudes, beliefs … These initial insights were just the beginning of many stories with issues that surfaced and influenced … Use of parent-centered safety culture tool (PCSCT) assessment. … Just as new parents were being identified, the COVID-19 epidemic put a stop to all activities. … The unit culture improved as well to include verbal report of UPEs in different forums.

1006. Strategy 1: Working with Patients & Families as Advisors (Implementation Handbook) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Best_Practices_Hosp_Leaders_508.pdf
      March 13, 2013 - This means telling patients’ stories, not just sharing statistics, when discussing successes and failures … clinicians and staff.(12) By sharing quality and safety data about the organization, leaders help create a culture … and support clinicians and hospital staff in patient and family engagement initiatives Creating a culture

1007. Improving Customer Service and Access in a Surgical Practice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/Case_Study_Specialty_Practice_Updated.pdf
      October 01, 2011 - • Gave Holiday bonuses to all specialty practice staff, not just those affiliated with the department … to query the medical center operations systems and seek out the data; the practice did not have a culture … The culture of the specialty practice and of the hospital as it relates to outpatient practices did … Managed Care 101 for general staff Front office staff who just passed the assessment examination; … and higher than the FPG average of 92. 45 STEP 6: MONITOR IMPROVEMENTS FOR SUSTAINABILITY Just

1008. Final Progress Report: SAFER: Standardizing Admissions for Elderly residents (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/coburn-report.pdf
      January 01, 2024 - inquiry method •Provide technical assistance to nursing facilities regarding AHRQ Patient Safety Culture … (%) readmissions •nfection rate •Error rate •Score on handoffs/ transitions on AHRQ Patient Safety Culture … to nursing facilities to pilot their first trial of the AHRQ Nursing Home Survey on Patient Safety Culture … a forum for sharing implementation strategies; a venue for sharing tools and forms; and pertinent, just-in-time … Many acknowledged challenges in finding the common ground among unique workplace cultures and practices

1009. Final Progress Report: Improving Patient Safety by Examining Pathology Errors (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/raab-report.pdf
      January 01, 2025 - implement and test at each institution were significantly limited by departmental and organizational cultures … All administrators articulated a belief in the value of Lean methods for achieving quality and safety … pay for performance should be introduced for the entire testing pathway (cross disciplinary) and not just … Transforming to a quality culture: The Henry Ford Production System. … Custom quality measures in healthcare: beyond Lean. 2007 World Conference on Quality and Improvement

1010. Measures of Implementation of Person-Centered Care Planning for People with Multiple Chronic Conditions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/mcc/pccp4p/measures-rapid-scan-report.pdf
      April 10, 2025 - In this case the measures would document what elements of PCCP are operational, and either just describe … Working with the Person’s Beliefs and Values 2. Sharing decision making 3. … So, with PROMs, if they use PROMs [in] that initial visit, they would just re-administer the PROM and … So as an example, let's just say hypothetically, if you were collecting data on a care plan, you could … And so that's just from the technical standpoint I think of the systems themselves.

1011. Case Example #2: The Health Center | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-2.html
      July 01, 2019 - threshold: 13% 151–200% of poverty threshold: 6% Unknown/not reported poverty threshold: 65% Cultural … backgrounds range from Scottish, Irish, and French backgrounds to Native Americans residing in Vermont … identify gaps in preventive care (e.g., immunization needs) for all THC patients systematically, not just … Building and Training “Everyone who works here contributes something that [is important]…you're not just … Information on medical treatments and results of new research are shared with all staff, not just the

1012. Chapter-3 - Sepsis Recognition (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/sepsis-1.pdf
      March 01, 2020 - staff about sepsis pathophysiology helps them to better understand and interpret screening parameters, just … Who Needs a Blood Culture? A prospectively derived and validated prediction rule. … 27%, resulting in approximately 1,053 fewer cultures per year. … Consecutive septic patients with positive blood culture; 526 patients. … The tradeoff for lower mortality was 10% more blood cultures obtained, and 5% more days on

1013. Optimizing Health and Function as We Age: Roundtable Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/healthy-aging-roundtable.pdf
      September 08, 2022 - healthcare delivery human networks • Approaches from complexity science • Rapid-cycle evaluation • Just-in-time … systems are attempting, one Roundtable member emphasized the following: The time that I spend is just … discussed barriers to scale and spread, including funding and payment mechanisms; metrics; necessity for culture … for each program, where fidelity to those elements is essential, and what can be adapted to local cultures … I’m saying, why can’t what I just went through, why can’t that be like when I’m taking care of my older

1014. Communication: Obstetric Hemorrhage - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
      July 01, 2023 - laboratory testing; and care decisions), Leadership (i.e., organizational planning, organizational culture … She lost 1,000 mL in the delivery room and another 250 mL just now. … She lost 1,000 mL in the delivery room and another 250 mL just now. … Just keep me updated about how you are feeling. … Silliness for this activity is encouraged, even if that’s not your typical unit culture.

1015. Communication: Obstetric Hemorrhage (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
      July 01, 2023 - laboratory testing; and care decisions), • Leadership (i.e., organizational planning, organizational culture … She lost 1,000 mL in the delivery room and another 250 mL just now. … She lost 1,000 mL in the delivery room and another 250 mL just now. … You are doing great; just keep me updated about how you are feeling. … Silliness for this activity is encouraged, even if that’s not your typical unit culture.

1016. Low Tidal Volume Ventilation Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-mvpguide.pdf
      January 01, 2017 - .............................................. 19 Execute: How Will We Implement LTVV Given Local Culture … therapists, and local hospital administrators is vital throughout the TRIP model continuum to create a culture … • Execute: How will we implement LTVV given local culture and resources? … them that improving the care of mechanically ventilated patients and including the use of LTVV is not just … Safety Program for Mechanically Ventilated Patients Execute: How Will We Implement LTVV Given Local Culture

1017. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
      July 18, 2008 - technology support, time pressures, inadequately trained personnel, financial constraints, organizational culture … revealed multiple modes of failure on the part of both the physician and patient in sharing information, beliefs … Enhancing interdisciplinary team collaboration45 to improve primary/ambulatory care46 and promote a culture … Much that is written about huddles does not distinguish the rapid huddle, just described, from a pre-procedure … Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire - ambulatory

1018. Engage Patients and Families for Perinatal Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/engage/pf-engagement-facilitator-guide.pdf
      May 01, 2017 - • Hospitals can present a very unfamiliar setting, system, and culture for patients. … provides continuous physical, emotional, and informational support to the mother before, during, and just

1019. Imbedding Research in Practice to Improve Medication Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Raebel_53.pdf
      May 07, 2008 - developing both the commitment to the Program and the trust necessary to imbed the Program within the KPCO culture … I just want to double-check with your physician before I fill the prescription.” … maintained as conducted during the research phase (with subsequent expansion to all patients, not just … I just want to double-check with your physician before I fill the prescription.” 5.

1020. Case Example #5: WellMed | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-5.html
      July 01, 2019 - WellMed is starting to focus on the culture of care between primary and specialty care with the goal … A WellMed nurse is onsite, available to all participants, not just WellMed patients. … Quality Improvement Efforts and Culture On the 4th Thursday of the month, the Medical Center clinic