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1841. Don't Dismiss the Dangerous: Obstetric Hemorrhage | PSNet
      psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
      August 21, 2024 - In such cases, hypotension is explained away as "the result of spinal or epidural anesthesia," or we just … Women complaining of increased postoperative abdominal pain are just "overly sensitive." … As a surgeon, I understand the subconscious impulse to deny that you may have just caused a major operative … learning actions, including huddles, debriefs, and monitoring outcomes, are the glue that creates the culture … significant hemorrhages Reporting and Systems Learning (Every Unit) Establish a culture

1842. In Conversation With… Rosemary Gibson, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
      September 01, 2014 - Beliefs are a factor. … When a child gets an adult dose of radiation, this is not just overuse. … An early elective delivery without medical necessity is not just overuse. … Overuse is a patient safety concern, not just a financial burden. … of overutilization," formed from the confluence of many reinforcing drivers, including a physician culture

1843. Medical Office Survey on Patient Safety Culture: 2018 User Database Report Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018mosopsdatabasereport-part1.pdf
      April 01, 2018 - Introduction Organizational culture refers to the beliefs, values, and norms shared by staff throughout … Patient safety culture is the extent to which these beliefs, values, and norms support and promote patient … Patient Safety Culture Composites and Definitions Patient Safety Culture Composite Definition: The extent … (F3R) 77 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.

1844. Medical Office Survey on Patient Safety Culture: 2018 User Database Report Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2018mosopsdatabasereport-part1-rev0921.pdf
      April 01, 2018 - Introduction Organizational culture refers to the beliefs, values, and norms shared by staff throughout … Patient safety culture is the extent to which these beliefs, values, and norms support and promote patient … Patient Safety Culture Composites and Definitions Patient Safety Culture Composite Definition: The extent … (F3R) 77 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.

1845. How are CHIPRA quality demonstration States supporting the use of care coordinators? Evaluation Highlight No. 9 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight09.pdf
      September 08, 2015 - individuals with the credentials, demeanor, and communication style that best fit their needs and culture … Matching care coordinators to practices’ needs and culture is essential Some characteristics, such … appreciative of my efforts and the fact that I offered to do care coordination for them so that they can just … be a mom or dad—just relieve a little bit of stress … Define CSHCN needs broadly so that a care coordinator focuses on more than just high- utilization patients

1846. Inside the epidemic of misdiagnosed women. | PSNet
      psnet.ahrq.gov/issue/inside-epidemic-misdiagnosed-women
      February 02, 2022 - June 23, 2021 Not ‘just depression.’

1847. Tip 2. In a Quality Report, Be Concise and Well-Organized | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/resources/writing/tip2.html
      July 01, 2011 - Some experienced report sponsors have cut down this content to the "bare minimum"—just enough to answer

1848. Critical Incident Reviews, Significant Adverse Event Reports and Action Plans. | PSNet
      psnet.ahrq.gov/issue/critical-incident-reviews-significant-adverse-event-reports-and-action-plans
      June 26, 2019 - July 22, 2020 Just a Cup of Tea – an Introduction to the SEIPS Framework.

1849. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33744/psn-pdf
      February 01, 2013 - Just do what we tell you to do." … Perhaps they've just received a new diagnosis and may not feel that they can even participate actively … We need to help both attending clinicians and trainees understand that we are not there just to answer … So even if the situation was just dreadful, mistakes were made, it was handled very poorly, can that … Yes, we need to improve patient experience scores, but much more importantly we need to change the culture

1850. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33774/psn-pdf
      December 01, 2014 - Or is this higher on Maslow's triangle, in that they're just not ready for it yet? … where people use the Internet to solve problems across these communities of practice that frankly just … You have that times 200 given all the countries and variations in resources and culture and history. … To just give an example from one of our close colleagues, Peter Pronovost, WHO has a special Patient … It's just not going to happen, or not going to happen easily.

1851. 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.

1852. 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.

1853. 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.

1854. 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.

1855. 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.

1856. 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

1857. 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.

1858. 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.

1859. 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

1860. 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