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1101. AHRQ Slide Template 2004 (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar01/sl_fuzzyset.ppt
      May 14, 2013 - CMgr visit documentation Incentives and barriers for CM use PO ownership Provider buy-in Practice culture … #2: Know your data Garbage in = Garbage out QCA is not a “turn the crank” type of analysis – can’t just

1102. Webinar #1: Fuzzy Set Analysis (Slide Presentation) | Agency for Healthcare Research and Quality
      www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar01/fuzzysets_slides.html
      July 01, 2013 - Practice culture. … #2: Know your data Garbage in = Garbage out QCA is not a "turn the crank" type of analysis – can’t just

1103. Meeting Minutes, March 2021 | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/events/nac/2021-03-nac/nacmtg031821-minutes.html
      July 01, 2021 - As defined in an executive order by President Biden, equity is the consistent, systematic, fair, just … long-term actions that the agency can take to advance health equity within three areas: ensuring a culture

1104. Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Leonhardt_35.pdf
      March 15, 2008 - Just as patients need education and tools to facilitate the medication process, provider issues must … by formal and informal leaders, was evidenced by the measure of penetration of the project beyond just

1105. 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

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. Engaging Stakeholders to Improve the Quality of Children's Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/implementation-guides/implementation-guide1/impguide1.pdf
      September 08, 2015 - a starting point and tailor the process of stakeholder engagement to fit your State’s priorities, culture … goals Your decision to formally engage stakeholders should be based on clearly defined goals, not just … “Blanket request[s] for input just don’t get answered. . . . … • Do you need to assess the entire stakeholder engagement process, or just certain elements? … Federation of Families’ core competencies for peer specialists, and then mapped stakeholder caregivers’ own beliefs

1108. 6. Research Gaps and Prioritization of Federally Funded HSR and PCR | Agency for Healthcare Research and Quality
      www.ahrq.gov/healthsystemsresearch/hspc-research-study/research-gaps.html
      June 01, 2020 - and I think we might even have more impact because then some of these very diffused findings, they just … One state-level representative said: “Workforce is just a constant struggle for us, understanding that … and patients: These specific outcomes, blood pressure control, hemoglobin A1c control, . . . they just … It’s just from experience: we know it’s way easier to move the quality needle than it is to move the … Or is it really that it’s just going to overburden busy primary care clinicians and that [it] really

1109. 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

1110. 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.

1111. 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

1112. 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.

1113. 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.”

1114. 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

1115. 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.

1116. 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

1117. 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.

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. 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

1120. 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