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Showing results for "just culture".
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  1. Improving the safety of intravenous admixtures: lessons learned from a Pentostam® overdose. | PSNet

    psnet.ahrq.gov/issue/improving-safety-intravenous-admixtures-lessons-learned-pentostamr-overdose
    January 04, 2017 - Citation Text: Just S, Schepers G, Piotrowski MM, et al. … Share Facebook Twitter Linkedin Copy URL January 2, 2017 Just … Linkedin Copy URL Cite Citation Citation Text: Just … Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture … September 20, 2011 Building and sustaining a systemwide culture of safety.

  2. In Conversation with…William B. Munier, MD, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
    July 01, 2011 - this does for the people doing the analysis, and for the institutions where they work, is create a culture … they do have peer review protection, provide it within institutional walls, and it may be limited to just … Speaking now just about the area we have addressed, which is patient safety in hospitals, we have created … might think that AHRQ would have specified what the common formats would be for national reporting, and just … That also gave us the opportunity to say, we're going to define a system that doesn't work just at the

  3. Medical Office Survey on Patient Safety Culture: 2018 User Database Report, Part II (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018mosopsdatabasereport-part2.pdf
    April 01, 2018 - It is just by chance that we don’t make more mistakes that affect our patients. … It is just by chance that we don’t make more mistakes that affect our patients. … It is just by chance that we don’t make more mistakes that affect our patients. … It is just by chance that we don’t make more mistakes that affect our patients. … It is just by chance that we don’t make more mistakes that affect our patients.

  4. Optimize Briefings and Debriefings: Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
    December 01, 2017 - Teamwork and culture improvement are a big part of this project. … Both safety culture and technical interventions must be managed to sustain progress. … Just the act of ticking off the box on a briefing checklist is not effective. … But an organization with a relatively poor safety culture saw minimal improvement from the checklist … Slide 27: Timeout: Prior to Incision Say: A timeout can occur just before incision to verify the

  5. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus (pdf file)

    integrationacademy.ahrq.gov/sites/default/files/2020-06/Lexicon.pdf
    January 01, 2020 - cultures. … Annotation: Isn’t this just good care in general? … cultures. … and roles as a clinician in the context of interdependency; customs (as expressed in workflows) for … , actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

  6. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
    June 01, 2005 - simultaneously studying clinical research, health policy, and management] was to combine those two cultures—quality … Their theories, which are often very elegant, are just not always applicable to bedside reality. … By exposing that, we revealed the dissonance between our pride and our belief that we are a great institution … PP: Unequivocally, they should start with culture change. … It simply says, measure your culture (we use J.

  7. Presentation: Engaging Senior Executives

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_sr-execs.pptx
    December 01, 2017 - For example, preventing surgical site infections is not just about giving the right antibiotic at the … Adaptive work addresses the attitudes, beliefs, and values of clinicians that drive behaviors, norms, … It is much easier to engage someone (anyone, not just executives) if you can be clear about what will … composite scores graphs Consider a brief safety culture summary, highlighting important points or culture … Don’t just invite them to come to the unit and walk through the OR with you.

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867850/psn-pdf
    February 26, 2025 - But they just were not being listened to. … High reliability and safety culture are fragile, and they need to be re- accomplished. … When that leader left, the culture reverted completely back to a much more traditional approach where … So let us just do them all together, and that will make us highly reliable. … One thing that came out of COVID was a pretty consistent finding that safety culture eroded.

  9. In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE | PSNet

    psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
    August 31, 2020 - Another experience that was of vital importance to me occurred just a couple of years ago when I met … That's just a fact. … feel comfortable to step up and speak up and protect patient safety, with action and not just words. … This is not something where you just came in one day and started hiring nurses who fill that safety culture … Or is it just a paradigm shift of how your thinking of the care you are providing?

  10. In Conversation with...Brent C. James, MD, MStat | PSNet

    psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
    February 26, 2025 - But we built from there and just started to expand out. … Yet you and others have written about the culture of medicine being so individualistic. … Now I would argue that this is the core of that culture. … We got to talking about exactly the issue that you just raised, the culture. As Dr. … But for adult learners this is just absolutely critical.

  11. Interpreting the Patient Safety Literature | PSNet

    psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
    June 01, 2005 - Safety culture assessment: a tool for improving patient safety in healthcare organizations. … simultaneously studying clinical research, health policy, and management] was to combine those two cultures—quality … By exposing that, we revealed the dissonance between our pride and our belief that we are a great institution … PP: Unequivocally, they should start with culture change. … It simply says, measure your culture (we use J.

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49495/psn-pdf
    December 01, 2005 - Subsequent urine cultures were negative. … Consider the lowest person in the hierarchy of a hospital, perhaps a young ward clerk (it could just … It was just a paperwork snafu, and the patient really was supposed to go to surgery. … Do her colleagues snicker at her, whispering just out of earshot during coffee breaks, while the surgical … Hospital Survey on Patient Culture.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33706/psn-pdf
    February 01, 2011 - But we built from there and just started to expand out. … Yet you and others have written about the culture of medicine being so individualistic. … Now I would argue that this is the core of that culture. … We got to talking about exactly the issue that you just raised, the culture. As Dr. … But for adult learners this is just absolutely critical.

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33831/psn-pdf
    April 01, 2017 - The second is safety culture. … Just do it the way I said." … Their culture is completely different. … That changes their culture. … Also, zero harm is not just getting rid of complications.

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33783/psn-pdf
    April 01, 2015 - LL: In a sense it's a mix—I think they fell prey to the belief that checklists are a simple thing. … you just do this one thing. … Why can't you just make it happen? … It just is not simple. … Finally, I think the culture change we seek will happen faster than we expect.

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33755/psn-pdf
    September 01, 2013 - Contemplate culture. … culture of a given organization and its subunits. … Creating a culture of safety requires leading differently. … undermine their ability to affect lasting change and create a learning orientation by focusing on just … ref7 https://psnet.ahrq.gov//#ref8 https://psnet.ahrq.gov//#ref9 https://psnet.ahrq.gov//#ref10 have beliefs

  17. Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective | PSNet

    psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
    June 01, 2016 - Successfully receiving CPPS recognition is rewarding and is consistent with my longstanding belief in … Culture. … It wasn't just the notion that culture has an impact on safety, but that it could be quantified or measured … Just focusing on joy and meaning without really looking at culture and leadership is also going to be … And that's not just physicians; the same is true of nursing.

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33712/psn-pdf
    June 01, 2011 - Editor's note: Edward Tenner is an independent writer, speaker, and consultant on technology and culture … First of all, are they so anticipatable that we should just now expect them? … that is that organizations can start to deviate from established procedures and bend them if in their culture … The culture created at the top is more important than any number of experts that you have there. … Japan's culture made it harder to discuss the risk.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33809/psn-pdf
    June 01, 2016 - It wasn't just the notion that culture has an impact on safety, but that it could be quantified or measured … Just focusing on joy and meaning without really looking at culture and leadership is also going to be … And that's not just physicians; the same is true of nursing. … The truth is that today we're getting more cross-fertilization, not just at the university level but … Just like we see in other fields, we're going to have individuals who are working in the area who are

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43571/psn-pdf
    October 01, 2014 - Following evidence that walkrounds improved safety culture, this practice became widely endorsed by … highlighting that failure to follow up on concerns raised may actually erode, rather than enhance, safety culture … effect-executive-walk-rounds-nurse-safety-climate-attitudes-randomized-trial-clinical-units https://psnet.ahrq.gov/primer/culture-safety … https://psnet.ahrq.gov/issue/i-think-we-should-just-listen-and-get-out-qualitative-exploration-views-and-experiences
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