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161. Developing a reporting culture: learning from close calls and hazardous conditions. | PSNet
     psnet.ahrq.gov/issue/developing-reporting-culture-learning-close-calls-and-hazardous-conditions
     February 26, 2025 - Sentinel Event Alerts Developing a reporting culture: learning from close calls and … Citation Text: Developing a reporting culture: Learning from close calls and hazardous conditions. … It highlights bright spots: organizations that use a just culture approach to investigating errors, … Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just … culture.

162. Making It Work Tip Sheet: Overcoming the Just in Case Mindset (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/just-in-case-mindset.pdf
     April 01, 2022 - bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) and improve safety culture … This can be impeded by a unit’s culture and clinicians who believe that it is safer for the patient … to have the catheter “just in case” the patient takes a turn for the worse. … An engaged culture is critical in creating an environment where clinicians understand the risk of increased … in Case” Mindset Issue Barriers Suggested Strategies Addressing Culture, Education, and Auditing

163. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-targets-slides.pptx
     June 01, 2021 - and beliefs Identifies system opportunities to prevent them from occurring again Identifying Targets … Clinicians are not using appropriate criteria to order urine cultures. … Pocket guides with criteria for when to order urine cultures. … Identifying Targets 15 Adaptive Problems Adaptive solutions require a change in attitudes, beliefs, … They should only be used when necessary, not “just in case.”

164. Mercy Health Uses AHRQ's Patient Safety Culture Survey and TeamSTEPPS® to Enhance Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201411.html
     August 01, 2014 - Mercy Health Uses AHRQ's Patient Safety Culture Survey and TeamSTEPPS® to Enhance Care Search All … largest nonprofit health systems in the United States, has used AHRQ's Hospital Survey on Patient Safety Culture … Mercy also uses the AHRQ resources to gain critical insights into opportunities to enhance safety culture … The Hospital Survey on Patient Safety Culture is a tool hospitals can use to assess their patient safety … Implementing "Just Culture Principles," which include creating an open and just environment, learning

165. Improving Patient Safety Culture – A Practical Guide. | PSNet
     psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide
     April 23, 2014 - Toolkit Improving Patient Safety Culture – A Practical Guide. … Citation Text: Improving Patient Safety Culture – A Practical Guide. … A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining … July 18, 2018 A Just Culture Guide. … January 31, 2018 Just a Cup of Tea – an Introduction to the SEIPS Framework.

166. Development of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Slide Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/smith2slides.pdf
     June 02, 2025 - do things around here” Exists at multiple levels: System Organization Department Unit Beliefs … Composites 27 items assess 8 composites of patient safety culture 1. … Never 88% positive 29 29 Communication About Patient Information % Positive Response Just … of procedures, all team members stopped to discuss the overall plan of what was to be done 92% Just … Safety Culture?

167. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39017/psn-pdf
     October 14, 2009 - Just culture: who gets to draw the line? October 14, 2009 Dekker SWA. … Just culture: who gets to draw the line? Cognition, Technology & Work. 2008;11(3). … https://psnet.ahrq.gov/issue/just-culture-who-gets-draw-line This commentary explores the just culture … https://psnet.ahrq.gov/issue/just-culture-who-gets-draw-line https://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives

168. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39475/psn-pdf
     September 04, 2010 - Influencing leadership perceptions of patient safety through just culture training. … Influencing leadership perceptions of patient safety through just culture training. … https://psnet.ahrq.gov/issue/influencing-leadership-perceptions-patient-safety-through-just-culture-training … This article reports on a Missouri effort to train health care leaders in the foundations of just culture … https://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives

169. Building a Safety Program in a Vast Health Care Network | PSNet
     psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
     March 01, 2019 - After developing a toolkit and workshop series focused on managing within a just culture, more than 1000 … Institution of just culture physician peer review in an academic medical center. … Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability … that they were a dot-com and we were a dot-org and that explained many of the different practices and beliefs … April 24, 2018 Institution of just culture physician peer review in an academic medical

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37590/psn-pdf
     April 13, 2018 - Just Culture: Restoring Trust and Accountability in Your Organization, Third Edition. … https://psnet.ahrq.gov/issue/just-culture-restoring-trust-and-accountability-your-organization-third-edition … He argues that a just culture in health care is critical to creating a safety culture. … https://psnet.ahrq.gov/issue/just-culture-restoring-trust-and-accountability-your-organization-third-edition … https://psnet.ahrq.gov/issue/just-culture-improving-safety-achieving-substantive-procedural-and-restorative-justice

171. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41449/psn-pdf
     February 13, 2019 - Just Culture and its critical link to patient safety—part 1 and part 2. … https://psnet.ahrq.gov/issue/just-culture-and-its-critical-link-patient-safety-part-1-and-part-2 This … to help hospitals assess their safety and establish a just culture. … https://psnet.ahrq.gov/issue/just-culture-and-its-critical-link-patient-safety-part-1-and-part-2 https … https://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives

172. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867525/psn-pdf
     January 15, 2025 - issue/teaching-nursing-students-ethical-and-legal-consequences-medical-errors- insights-radonda A just … culture ensures that staff feel safe reporting errors without fear of reprisal or retaliation. … culture. … teaching-nursing-students-ethical-and-legal-consequences-medical-errors-insights-radonda https://psnet.ahrq.gov/issue/improving-patient-safety-practicing-just-culture … prosecution-radonda-vaught-ethical-and-legal-mistake https://psnet.ahrq.gov/issue/role-regulator-enabling-just-culture-qualitative-study-mental-health-and-hospital-care

173. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-slides.html
     July 01, 2023 - Just Culture. Image: TeamSTEPPS penguin and logo—as seen in TeamSTEPPS®. … Slide 12: Introduction to Just Culture Principles Introduction to Just Culture Principle Slide … 13: Understand Just Culture Image: Opening shot of Just Culture video with the words "Click to play … Blame-free culture: no accountability. Just culture: optimally supports a system of safety. … Just Culture . Plano, TX: Outcome Engineering; 2011.

174. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Material Use Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/guide.html
     March 01, 2017 - Overview of Toolkit Modules Slides 6–13 Implementing Change Slides 14–16 Just … During the meeting, obtain a commitment from leaders to improve safety culture. … Materials: Slides 14–19 Audience: LTC administrators and leaders Topic: Just Culture Method: During … a meeting, use the slides and facilitator notes to define and discuss the principles of Just Culture … Through an open discussion or a written exercise, ask the team to reflect on what elements of Just Culture

175. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43051/psn-pdf
     May 29, 2014 - A just culture after Mid Staffordshire. May 29, 2014 Dekker SWA, Hugh TB. … A just culture after Mid Staffordshire. BMJ Qual Saf. 2014;23(5):356-8. … https://psnet.ahrq.gov/issue/just-culture-after-mid-staffordshire In the context of public reactions … The authors advocate for a just culture that balances blame and accountability to address complexities … https://psnet.ahrq.gov/issue/just-culture-after-mid-staffordshire https://psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry

176. Culture | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/clabsi-cauti-icu/overcome/culture.html
     April 01, 2022 - Culture A strong patient safety culture supports a learning environment and invites diverse input … Use these tools to help your team make lowering infections part of your culture.​ … Examples of common barriers that inhibit developing this culture are ineffective action from leaders, … in Preventing Healthcare Associated Infections (PDF, 291.7 KB) Making It Work – Overcoming the "Just

177. Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module1/guide.docx
     March 01, 2017 - Infection Prevention Overview of Toolkit Modules · Slides 6–13 Implementing Change · Slides 14–16 Just … During the meeting, obtain a commitment from leaders to improve safety culture. … Materials: Slides 14–19 Audience: LTC administrators and leaders Topic: Just Culture Method: During … a meeting, use the slides and facilitator notes to define and discuss the principles of Just Culture … Through an open discussion or a written exercise, ask the team to reflect on what elements of Just Culture

178. ‘Ladder’-based safety culture assessments inversely predict safety outcomes. | PSNet
     psnet.ahrq.gov/issue/ladder-based-safety-culture-assessments-inversely-predict-safety-outcomes
     January 22, 2025 - ‘Ladder’‐based safety culture assessments inversely predict safety outcomes. … High-reliability organizations frequently assess the strength of their safety culture. … ‘Ladder’‐based safety culture assessments inversely predict safety outcomes. … Download Citation Related Resources From the Same Author(s) Restorative just … June 24, 2020 Integrating principles of safety culture and just culture into nursing

179. SOPS™ 101 Webcast Transcript (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-webcast-transcript.pdf
     June 01, 2020 - This is summarizing what I've just said. … Gray, Slide 11 Patient safety culture can be defined as the beliefs, values, and norms that support … These beliefs, values and norms are shared by healthcare providers and staff in the organization. … If you just focus on one unit that, could be good for patient safety culture improvement just for that … and Just Culture.

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837859/psn-pdf
     August 17, 2022 - The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. … The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. … https://psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review … Underutilization of error reporting systems may be due to a variety of factors, including a culture … https://psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review