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1041. 043-Vap-Prevention-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/043-vap-prevention-notes.docx
      October 01, 2024 - CUSP team champions can assist with assessments of unit culture, determining future education needs, … interventions are applicable to most ventilated patients, the emphasis on early mobility becomes part of the culture … The CUSP executive leader has just joined the team, as the previous leader retired, and this executive … This protocol requires purchasing a custom oral care kit that makes it easy for staff to have what they

1042. New Models of Primary Care Workforce and Financing - Case Example #2: The Health Center (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_2.pdf
      October 01, 2016 - 151–200% of poverty threshold: 6% • Unknown/not reported poverty threshold: 65% ▌pg. 2 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

1043. Final Progress Report: Diagnostic Error in Medicine Annual Conference (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/singh2-report.pdf
      January 01, 2025 - Error Through Improvement of Laboratory Test Utilization Day 1 Sessions • Keynote Presentation: It’s a Culture … • Overall, 229 of the 234 attendees were there for the main conference (19 attended for just 1 day … • Overall, 258 of the 284 DEM attendees were there for the full conference (26 attended for just 1

1044. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/corbett.html
      August 01, 2017 - Member, and Clinician Perceptions of Disclosure of Adverse Events in Labor and Delivery Patient Safety Culture … Measurement, Analysis, and Interpretation: A Commentary Error Disclosure Training and Organizational Culture … medication risk management efforts focus on preventing errors by improving systems and creating safety cultures … The patient brings in a reconciliation sheet, and it looks just like the discharge (prescription) sheet … Coalition is attempting to change the culture of full disclosure and offers resources for health care

1045. Final Progress Report: Measuring Mistrust in Healthcare (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/laveist-report.pdf
      January 01, 2024 - Trust is the belief that one will not exploit the vulnerability of another (Sable 1993). … But on what basis does one come to this belief? … Control refers to the belief that those who are entrusted with their care will assume responsibility … Just below 75% of respondents had at least a high school education, and 22.1% were college graduates

1046. Final Progress Report: AUA 2022 Quality Improvement Summit: Opportunities to Improve Care in Urology (pdf file)
      www.ahrq.gov/sites/default/files/2024-05/gore-report.pdf
      January 01, 2024 - early in the disease process, preferably at the time of diagnosis, engaging the patients’ values, beliefs … diversity of social determinants, such as environment, personal characteristics, family, spiritual beliefs … , culture, race, and language. … They noted that palliative care helps patients to live within the goals of care, not just die within … older physicians, pain management is problematic in the current climate, and there is a longstanding belief

1047. 005-Ss-Preop-Chlorhexidine-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/005-ss-preop-chlorhexidine-fg.docx
      April 01, 2025 - and morning of surgery, and then were randomized to receive 5 days of either mupirocin or iodophor just … The purulent drainage is sent for cultures, and he is given a prescription for oral antibiotics.

1048. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
      January 01, 2024 - risk model that represents the complex 4 relationships between system elements, organizational culture … This PADE was also applicable to any medication, not just the high-alert drugs under study. … The team also estimated the probability of capturing a dose/strength error at just 20% with a duplicate … For example, the modeling team estimated that a pharmacist would fail to capture the error in just one … Medication safety: patients’ experiences, beliefs, and behaviors. J Am Pharm Assoc.

1049. Using Patient Complaints to Promote Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Pichert_51.pdf
      March 22, 2008 - We hypothesized that patient/family concerns would just as likely point to recurring problems that increase … While we certainly agree that “reducing lawsuits requires preventing errors and improving safety, not just

1050. Primary Care Practice Facilitation Curriculum Module 7: Professionalism for Practice Facilitators (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-7-professionalism.pdf
      September 01, 2015 - as a means for having a staff member or clinician reflect on any ambivalence about the process, the culture … After a long day (and a drive home ahead), it can be tempting just to slip out the back door. … Taking the time to say goodbye (just like saying hello) can be an important step in building rapport … When working with patients or practice members from cultures, backgrounds, or experiences different … using a snowball approach, clear this with your practice champion and be sure that you respect the culture

1051. Guide: Purpose and Use of CLABSI Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/clabsi-tools/guide.html
      January 01, 2020 - interpersonal communication improved aviation safety, the same is not yet true in health care's hierarchical culture … CLABSI in clear, real terms and present the actual number of infections over a period of time, not just

1052. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
      May 05, 2008 - industry, the integrity of this environment is the responsibility of all providers at the bedside, not just … hierarchy, mutual respect within and across disciplines and situational awareness—are key components of a culture … The impact of culture on technology.

1053. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
      January 01, 2004 - including: (1) using distinct drug names; (2) standardization; (3) encouraging the development of a culture … These “weighted value” scores are just the sum of the error reduction weights of parameters that are … Skill System Design Workload External Checks Weighted value Weight 0.7 0.1 0.1 0.8 0.9 Culture … The two most prioritized error-reduction practices, culture of safety and human factors (HF) principles

1054. Best Practices in the Diagnosis and Treatment of Clostridioides difficile Infections (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/CDI-facilitator-guide.pdf
      November 01, 2019 - Moment 2: Have I ordered appropriate cultures before starting antibiotics? … retested to confirm the patient indeed has CDI by testing specifically for the presence of toxin and not just

1055. Final Progress Report: Improving ED Quality and Safety by Enhancing Operations and Quality Management (pdf file)
      www.ahrq.gov/sites/default/files/2024-09/khare-report.pdf
      January 01, 2024 - The applicant’s interest in this topic emanated from his belief that improved healthcare delivery systems … qualitative methods, such as Failure Modes Effects Analysis, clinician surveys about organizational culture … High-quality care requires more than just excellent medical decision making and physician buy-in to

1056. Patient-Centered Outcomes Research Trust Fund Strategic Framework (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pcor/pcortf-strategic-framework.pdf
      June 01, 2023 - organizational factors; community-level factors; and individual factors) that can advance fair and just … CDS isn’t just an afterthought that can simply be added on as a mechanism or tool for a project with … personal characteristics, including but not limited to: age, gender, sexual preference, race, ethnicity, culture

1057. Primary Care Practice-Based Research Networks and Publications, 2014–2023: Synthesis Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/pbrn/pbrn-final-synthesis-report.pdf
      September 01, 2025 - transformation, including community engagement, health information technology, and organizational culture … Organizational Culture, Teamwork, and Communication Includes studies such as Team Strategies and … Tools to Enhance Performance and Patient Safety (TeamSTEPPS) and culture surveys. … Just under half (n=40) of these PBRNs were established 10 to 20 years ago, with nearly as many (n=32 … , Teamwork, and Communication organizational culture, teamwork, communication, TeamSTEPPS, culture

1058. Pressure Injury Prevention Program Phases | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/phases.html
      September 01, 2017 - The team should focus on just a few key interventions. … the interventions and improved outcomes normal, integrated, and mainstream—part of your hospital’s culture

1059. How are CHIPRA Quality Demonstration States encouraging health care providers to put quality measures to work? | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight05.html
      November 01, 2013 - quality improvement (QI), they should: Develop an overall program design that suits the needs and culture … holding practices and health systems more accountable for all of the patients in their practice, not just

1060. Developing an Effective Care Coordination System Implementation Guide
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/care-coordination-slides.pptx
      January 01, 2018 - If you are just beginning to plan your QI initiative, you may want to start by reviewing the slide deck … patients’ enrollment and participation. 26 Common Barriers to CR Individual Concerns Cultural values/beliefs