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1901. 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

1902. Indwelling Urinary Catheter Insertion Facilitator Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-insertion-notes.docx
      April 01, 2022 - Blood cultures are positive for E. coli. … You can see that the checklist is divided into sections, with each section consisting of just a few items … , so that a new cotton swab becomes contaminated by wisps from the previous swab, so many inserters just … in the ICU, when a mistake is made blood starts to spurt, or patients stop breathing and turn blue, just … Instead of just performing a task, the person reflects on what that means to the patient and what could

1903. Operationalizing Patient Safety at Academic Medical Centers | PSNet
      psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
      August 01, 2010 - change in the culture of future clinicians. … Setting such a culture will require a commitment from senior leadership ( 4 ), along with faculty and … Once you ingrain the process as a culture, I think it is sustainable. … exists in Pennsylvania, Penn's desire to really try to be great in this domain, and my commitment and belief … When you begin to codify them, it's just staggering.

1904. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/implementation-guide_0.pdf
      September 01, 2015 - Culture consists of the unit team’s values, attitudes, and beliefs, which will all have an impact on … CUSP helps hospital units move from a culture in which a punitive response to error prevails to a culture … , evaluate current processes for obtaining urine cultures (e.g., avoid urinalysis or urine cultures … Using the knowledge of those who cared for the patient just before their symptoms began improves understanding … Improving the Culture of Culturing: Avoiding Unnecessary Urine Cultures in Catheterized Patients.

1905. Toolkit for Reducing CAUTI in Hospital Units: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide.pdf
      September 01, 2015 - Culture consists of the unit team’s values, attitudes, and beliefs, which will all have an impact on … CUSP helps hospital units move from a culture in which a punitive response to error prevails to a culture … , evaluate current processes for obtaining urine cultures (e.g., avoid urinalysis or urine cultures … Using the knowledge of those who cared for the patient just before their symptoms began improves understanding … Improving the Culture of Culturing: Avoiding Unnecessary Urine Cultures in Catheterized Patients.

1906. Final Progress Report: Workshop on Consumer Engagement in Selected Patient Safety Topics (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/hatlie-report.pdf
      January 01, 2024 - that human beings co-create what is thought to be “reality” through language, thoughts, images, and beliefs … - 6 - thoughts, beliefs, and language that shift current mental models about what is (“patients … engage participants as creative partners, perhaps prompting them to re-examine their own thoughts and belief … culture” or these penalties will not be seen to be fair. … Just culture = does not tolerate reckless disregard for the consequences of an action.

1907. Using Telehealth to Improve Quality and Safety (pdf file)
      digital.ahrq.gov/sites/default/files/docs/lesson/09-0012-ef-telehealth.pdf
      December 01, 2008 - ..................................................................10 Teamwork and Organizational Culture … 10 percent of specialists practice in these areas.3 Lack of access to medical specialists is not just … However, this often requires the participation and cooperation of many individuals, not just IT department … They found that providers at all three sites reported improved attitudes about teamwork and the culture … Technical Support Organizational Issues Evidence­Based Practice Teamwork and Organizational Culture

1908. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851870/psn-pdf
      July 31, 2023 - the Patient Safety Authority looks at events across the entire healthcare system in Pennsylvania—not just … The more difficult part of organizational learning becomes building that culture where staff is comfortable … Building that culture starts with leadership and it needs to reach the frontline. … It’s often not people purposefully avoiding reporting events; sometimes, they just do not know what … You must begin to build a culture to encourage reporting where people know that reporting is worth their

1909. Tailored DVD to Improve Medication Management for Low Literate Elderly Patients (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017281-lapane-final-report-2010.pdf
      January 01, 2010 - The length of the DVDs was "just right" (90+%), with 40% sharing the DVD and 48.4% watching the DVDs … A vast majority (95.4%) said that the lengths of the DVDs were just right. … They also 11 found the spacing of the DVD delivery to be just right (87.7%). … Ninety one percent said the amount of print materials they received were just right. … Medication Management Beliefs and Practices Of Low Income Older Adults From Diverse Racial/Ethnic Populations

1910. Be Prepared to Be Engaged | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/engage/interventions/prepared-slides.html
      May 01, 2017 - Project Goals Meaningful engagement with patients and families in ways that impact safety, not just … The figure also shows that external factors such as the health care system, culture, community, and environment

1911. WNYHealtheNet, LLC: A Collaborative Administrative Transaction Network Model (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006ScamurraUnger_051711comp.pdf
      June 05, 2006 - operating costs through shared resources Protect Patient Information Benefits  Creates a community culture … community-wide standards  Gain significant business value from transactions by utilizing MORE than just

1912. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/131-ss-swiss-cheese.pptx
      April 01, 2025 - His wound culture was positive for MRSA. … every hour (6.5 per 8-hour shift), effectively removing 1 in every 15 nurses from patient care duties just

1913. Performing SSI Investigations: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/ssi-investigation-slides.html
      December 01, 2017 - Completed safety culture survey (HSOPS)? … was the patient’s temperature at the following locations: Arrival to preoperative area At or just

1914. The Safety Challenges of Supervision and Night Coverage in Academic Residency | PSNet
      psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
      February 21, 2024 - (10,11) A second key element to successful teaming is the development of a psychologically safe culture … through inclusive leadership, a work environment focused on continuous improvement and by achieving a just … culture that appropriately acknowledge individual- and system-level factors. … The three pillars of a teaming culture. Harv Bus Rev. December 17, 2013. … Available at https://hbr.org/2013/12/the-three-pillars-of-a-teaming-culture 9.

1915. Ventilator-Associated Event Surveillance: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/vae/surveillance-fac-guide.html
      February 01, 2017 - It helps us focus on the importance of preventing all complications resulting from pneumonia, not just … On the other hand, diffusion comes from your culture. … Just remember, change takes time and patience. … You may have an electronic health records system, but it helps to just gather the data and look at it … Just by looking at this one simple case, we can see several opportunities for improvement.

1916. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet
      psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
      June 14, 2023 - My work, beliefs, and commitment have been shaped by early life experiences. … These partnerships need to be foundational to the culture of the organization. … That type of list just makes so much sense. … Hospitals are beginning to change the concept of families as “visitors,” returning to the belief that … Some places just shut down their PFACs.

1917. The How-To’s of Hand Hygiene | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/hand-hygiene/hand-hygiene-slides.html
      March 01, 2017 - Just Clean Your Hands educational resources. Ontario Agency for Health Protection and Promotion . … How can I help support a culture of safety around improving hand hygiene in our facility? … Just Clean Your Hands educational resources. Ontario Agency for Health Protection and Promotion .

1918. Making Do | PSNet
      psnet.ahrq.gov/web-mm/making-do
      September 05, 2018 - However, post-operatively, the patient developed fevers, and blood cultures grew Actinomyces . … The astute physician will remember that expertise lies not just in manual dexterity, careful surgical … November 18, 2016 Association of diagnostic stewardship for blood cultures in critically … ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative

1919. In Conversation With…David C. Classen, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
      May 01, 2012 - some triggers might be essentially perfect correlates of what you're looking for (a positive blood culture … But, when we do it electronically, it's not just preventability—it's the ability to actually intervene … in real time and to mitigate rather than just prevent—so it changes the equation. … Building a safety culture clearly has a big part in enabling people to report problems in the system … One argument is that this effort is an essential part of building a culture of safety.

1920. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33638/psn-pdf
      August 01, 2006 - The opportunity to spend my formative years immersed in a real safety culture embedded safety in my … learned an important lesson: enlightened, risk-taking leadership is the only way to achieve significant culture … Some of the gains have come through changes in culture (for instance, assigning more value to safety … often ask audiences, why can't we have large signs in every health care facility lobby, stating not just