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981. Situation Monitoring: Severe Hypertension (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring-speaker-notes.pdf
     July 01, 2023 - Huddles may require attendance from more than just the bedside nurse and attending. … Smith, your labs just returned and are notable for an elevated protein/creatinine ratio and elevated … • How do we prepare now so that we are ready to handle the next event in the way we have just discussed … Debrief after events to support patients, families, and staff Debrief regularly to establish a culture … Regular debrief sessions after such events help to establish and sustain a culture of continuous learning

982. The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Karsh.pdf
     April 08, 2004 - error causation; human error; tools to assess safety and risk; systems design principles; safety culture … have included system redesign, error reporting systems, information technology, and improved safety culture … In addition, just like physicians, their work in health care has a direct impact on patient safety, … theories, and methods • Medical error causation • Safety tools to assess safety and risk • Culture

983. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
     January 01, 2024 - Just over 10% (exactly 10.2%) of reports were associated with known clinical harm to the patient. … suggest that perceived clinician indifference to a bad outcome led to patients’ loss of trust and a belief … The powerful effect of a safety culture, and the lack of understanding of high-performance systems, … and qualitative approaches to determine the useful level of detail based on empirical data, not just … a culture of safety in primary care.

984. III. Hotline Implementation and Refinement | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/implement3.html
     May 01, 2016 - organizations’ policies and training materials related to patient safety to confirm that they upheld “just … culture” principles, emphasized opportunities for learning rather than blaming individuals, and recognized

985. Strategy 1: Working with Patients & Families as Advisors (Implementation Handbook) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Best_Practices_Hosp_Leaders_508.docx
     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

986. Communication Assessment Guide: Appendix 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap2.html
     August 01, 2022 - I will be able to let you see her in just a few moments."

987. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
     January 01, 2024 - problems, or problems related to components of healthcare delivery systems, such as technology, workflow, culture … anywhere in a healthcare delivery system; they represent interactions between clinicians, patients, culture … Similarly, on PCP severity, 4 was permanent/stress whereas 3 was temporary discomfort or just annoyed … The FMEA of just the step “obtain information from an external provider” required eight meetings, each … preliminary meetings, that means each physician contributed at least 30 hours to the completion of just

988. Final Progress Report: How Do Consumers View the Risks of Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
     January 01, 2024 - instrument in the patient; operating on the wrong patient or wrong limb, or unnecessarily on the heart; or just

989. Medical Team Training Programs in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Baker.pdf
     February 01, 2005 - shown to believe that ACRM contributes significantly to the safe practice of anesthesiology, and these beliefs … In contrast, MTM specifically fosters a culture that values team performance and encourages effective … communication.22 Its theoretical position is that this new culture will facilitate teamwork, thereby … Culture at work in aviation and medicine: national, organizational, and professional influences. … Just what is a competency (And why should we care?). Training 1998;35:58. 37.

990. Summary of the 2018 AHRQ CAHPS Research Meeting (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/survey-methods-research/summary-research-meeting.pdf
     January 01, 2019 - Most importantly, the speakers addressed the importance of not just using multiple survey modes, but … for the language around them to be engaging; those administering these surveys can’t assume that a “just … discharge period was too brief; in others, the parent was not available to answer the survey until just … Noting that 7 www.ahrq.gov/cahps | the use of telephones is no longer a strong part of our culture

991. AHRQ Stats | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/ahrq-stats.html
     July 01, 2025 - Just 6.8 percent of non-Hispanic White patients experienced the same communication gaps. … In-hospital delivery stays for Asian/Pacific Islander women included the lowest diagnosis rate, at just … both private insurance and dental coverage visited both a medical and dental provider, compared with just … Patient Safety Culture in Nursing Homes Nursing home staff completing AHRQ's Nursing Home Survey on Patient … Safety Culture in 2019 gave the highest positive response— 85 percent—to "overall perceptions of nursing

992. Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Engleman_86.pdf
     June 04, 2008 - For instance, the culture in many hospital laboratories fosters reporting only to manufacturers and … Feedback to the FDA about laboratory device reporting from such forums verified a culture of reporting … Human Tissue and Cell Subnetwork Just as CDRH regulates medical devices, CBER regulates human cells … These visits were undertaken to obtain information on organizational culture, with a special emphasis

993. Evaluation and Research on Antimicrobial Stewardship's Effect on Clostridium difficile (ERASE C. difficile) Project: toolkit (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/cdifftoolkit.pdf
     September 01, 2012 - Participating Facility Reflections  Narrowing the focus from several to just one antibiotic target … If your facility is just starting ASP efforts or has little IT support, purchasing can be both a feasible … prescribing can be good and bad, so reviewing the patterns of antibiotic prescribing in general and not just … Based on the AHRQ Hospital Survey on Patient Safety Culture. … If selected, urine culture with followup is recommended.

994. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/primary-care-research/results.html
     January 01, 2024 - , a PBRN Registry , and fund the annual PBRN International Conference. 31 PBRNs have fostered the culture … Visionary leadership and a supportive culture ease the way for change. … anything else is the name [PCMH] matters less than the substantive changes behind it…keeping in mind it is just … I actually was just looking at an AHRQ report today about mobile health apps for improving diabetes control … Pronovost has remarked that the broad impact of CUSP "started with just an initial $500,000 investment

995. Provider CHCANYS Qualitative Interview Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/interview-protocol-qi-ny.pdf
     June 02, 2025 - What has been the biggest challenge in making the changes we just discussed?

996. 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.

997. AHRQ Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Grants: A Synthesis Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/tpc/final-impact-synthesis-report.pdf
     July 22, 2015 - Components ..........................................................................4 Building a Culture … Building a Culture of Change Across Stakeholders Stakeholder participation in IMPaCT extension program … Just as this type of relationship building had been critical in the success of spread activities within … They also help primary care providers understand and adapt to local culture. … of Change in Primary Care Building a Culture of Change Across Stakeholders Who Were the Extension

998. AHRQ Infrastructure for Maintaining Primary Care Transformation (IMPaCT) Grants: A Synthesis Report (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/final-impact-synthesis-report.pdf
     July 22, 2015 - Components ..........................................................................4 Building a Culture … Building a Culture of Change Across Stakeholders Stakeholder participation in IMPaCT extension program … Just as this type of relationship building had been critical in the success of spread activities within … They also help primary care providers understand and adapt to local culture. … of Change in Primary Care Building a Culture of Change Across Stakeholders Who Were the Extension

999. Implementation Guide for Ambulatory Care Antibiotic Stewardship (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/antibiotic-stewardship.pdf
     September 01, 2022 - If you are just starting to implement antibiotic stewardship activities in your practice, the resources … appropriate diagnostic criteria to determine if a patient has an infection, common causative organisms and cultures

1000. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/infection-prevention/environment-and-equipment/environment-equipment.pptx
      March 01, 2017 - residents’ rooms, disinfecting surfaces and equipment and using isolation precautions when necessary are just … during bathing or showering) Disinfect port with alcohol swab for 15 seconds before obtaining a urine culture … Just Clean Your Hands educational resources.