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1101. Chapter 3. Care Coordination Measurement Framework | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/care/coordination/atlas/chapter3.html
      June 01, 2014 - payment structure, patient complexity and capacity (e.g., Chapter 2 patient scenarios ), and local culture … These are also usually wide in scope, with goals of improving aspects of patient care beyond just care

1102. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
      July 01, 2023 - Respondents with limited education or from cultures that discourage challenging professional authority … We just changed doctors. We no longer trust white doctors. following the medical error.” … shortfalls, it would be essential to include elicitation questions as part of population-based surveys, not just … But that is just the start of an extended process of methodological refinements.

1103. Technical Review 17: Nutritional Research Series, Vol. 1: Application of Systematic Review Methodology to the Field of Nutrition (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/nutrtp1.pdf
      January 01, 2009 - These questions may be just a few among many needed to address an overarching topic. … Health Effects of (n-3) Fatty Acids on Arrhythmogenic Mechanisms in Animal and Isolated Organ/Cell Culture … Effects of Omega-3 Fatty Acids on Arrhythmogenic Mechanisms in Animal and Isolated Organ/Cell Culture … arrhythmia outcomes Different for whole animal, intact animal isolated organ and cell, and cell culture … from whole animal studies that (n-3) fatty acids affect arrhythmogenic outcomes Evidence from cell culture

1104. Challenges to Real-Time Decision Support in Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
      January 01, 2007 - safety and outcomes rely on strategies to ameliorate or eliminate the impact of human limitations.5 A “culture … The coordination of multiple activities12 may be just as critical for patient survival as making the … The algorithm designer is a separate custom built tool that allows the graphic representation of algorithms

1105. Improving Communication and Teamwork in the Surgical Environment Module: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/improving-fac-notes.html
      May 01, 2017 - Before you start work to improve communication and teamwork, consider administering a culture survey … One example used by many facilities is the AHRQ Survey on Patient Safety culture. … seeking information concerning ways to improve the safety and efficiency of the procedure that was just

1106. Case Report on Ambulatory Safety and Quality (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-casereport.pdf
      September 05, 2017 -  Practices can use just the tools most relevant to their purposes and even adapt them as needed … review that should be embedded in safety improvement activities as part of a larger effort to create a culture … position specific improvements in larger context of promoting organizational learning, fostering a culture … and talking openly about things that work and don’t work, which indicates a supportive climate and culture … FM residency put it, “It’s been nice, for the most part, the provider survey, things like that, to just

1107. The Impact of Standardized Order Sets on Quality and Financial Outcomes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Ballard_12.pdf
      February 02, 2008 - The long-term goals for this project include: • Creating a culture that fosters interdisciplinary … Just-in-time training provided to nursing units at some BHCS acute care hospitals. 3. … PN-3b blood culture before first antibiotic. 4.

1108. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/simulation-brief.pdf
      February 01, 2015 - Recognizing simulation is not just for residents and nursing students: The education and training … Just as it takes considerable practice for learners to acquire new skills and reach a high standard

1109. Department of Health and Human Services National Institutes of Health - National Institute for Research on Safety and Quality (NIRSQ) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/mission/budget/2021/FY_2021_CJ_NIRSQ.pdf
      January 01, 2021 - Better teamwork and the establishment of safety cultures in healthcare organizations are critically … This project has just begun and the module is expected to be completed in January of 2021. … AHRQ developed SOPS to support a culture of patient safety and quality improvement in the Nation's health … The safety culture surveys and related resources can be used by hospitals, nursing homes, medical offices … SOPS can be used to assess the safety culture of individual units and departments or organizations as

1110. Final Progress Report: The Institute for the Design of Environments Aligned for Patient Safety (IDEA4PS) (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/mcalearney-report.pdf
      January 01, 2024 - care team members, our findings suggest that inpatient portals may facilitate shifts in organizational culture … Assessing the relationship between patient safety culture and EHR strategy. … A Roundtable Discussion: Improving the 'Alarm Problem' Will Require Much More Than Just Reducing the … Building a Culture of Wellness: An Interdisciplinary Panel Discussion With Q&A. … Custom Alarm Design: You Don’t Have to “Crank it up to 11.”

1111. From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
      February 09, 2005 - Each facility had a unique history and culture with regard to warfarin care. … I think that patients on warfarin—whether it was cardiac, ortho, or whatever—I think we were just being … through the Palm Pilot, it would take close to an hour Advances in Patient Safety: Vol. 3 404 just

1112. Final Progress Report: Putting a Face on Hospital Medical Errors: Communication (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/stewart-report.pdf
      January 01, 2024 - Other information about demographics, knowledge, attitudes, beliefs, and previous experiences with the … However, receiving a letter seemed to instill greater trust in respondents when it was just a “close … Others described a disrespect based on ethnicity/culture.

1113. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.pdf
      August 01, 2010 - The Nurse Bedside Shift Report strategy is flexible and adaptable to each hospital’s environment and culture … nurses may be hesitant to disturb the patient, especially if the patient has been awake all night and just … Creating this new culture of bedside shift report for nurses was a process and a challenging one at … Culture change through patient engagement. Nursing 2010 Oct;40(10):50–2.

1114. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
      March 01, 2002 - More than 50 percent of the preventable adverse drug events in RMEES were associated with just 14 drugs … including reporters’ perceptions of the severity and extent of risk that the event poses, reporting culture … punishment, and liability concerns.49 Equally compelling is the notion that reporting could reflect the culture … This further supports the importance of local unit culture and individual attitudes in determining reporting

1115. Chapter-2 - Failure-To-Rescue (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/failure-to-rescue-1.pdf
      March 01, 2020 - • Poor safety culture and hierarchies inherent in healthcare are barriers to successful implementation … positive perception of the RRT, suggesting that educational efforts, rather than time, drive lasting culture … response team in fear of the call being viewed “as an acknowledgment of inadequacy on their part.”10 Just … as a culture of clear communication and teamwork can help to facilitate successful RRT implementation

1116. How are CHIPRA Quality Demonstration States working to improve adolescent health care? | Agency for Healthcare Research and Quality
      www.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/highlight03.html
      August 01, 2013 - We’re changing that culture and identifying and flagging. … all kinds of things when you get the [questionnaire] back that you wouldn't have seen or heard about just

1117. Presentation: Science of Improving Patient Safety and Identifying Defects
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
      December 01, 2017 - This requires a culture where frontline providers feel comfortable speaking up and have confidence their … Safety Assessment (PSSA) Four-question survey Completed by ALL staff members in the clinical area, not just

1118. Pediatric Diagnostic Safety: State of the Science and Future Directions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-pediatric-safety.pdf
      September 01, 2023 - the Diagnostic Process and Missed Diagnostic Opportunities in Pediatric Care Settings We have only just … diagnostic uncertainty,134 ■ Teamwork and communication,135 ■ The clinical work environment and culture … Teamwork, team cognition, safety culture, communication, and patient/family-centeredness are some of … technologies, AI’s thoughtful implementation into complex clinical workflows must be carefully considered just … Patient Safety Culture, Health Information Technology Implementation, and Medical Office Problems That

1119. Final Progress Report: Evaluating the Impact of Simulated Team Training on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/scott-report.pdf
      January 01, 2024 - Create a culture of safety by increasing vigilance and prevention of adverse events and outcomes through … Our center has just completed construction of a new dedicated virtual OR, such that we can continue

1120. TeamSTEPPS for Improving Diagnosis Facilitator's Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-facilitators-guide.pdf
      February 04, 2022 - They are exactly the same, just a different view. … Did your perspective change once you read that the two images are the same, just presented in a different … � Lab data (culture data, respiratory viral panel, COVID testing, beta natriuretic peptide, D-dimer, … and initiate empiric treatment while awaiting additional results (e.g., antibiotics while awaiting culture … accident, a patient receives a call that says to contact an orthopedic physician; a wrist fracture was just