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1921. Presentation: Optimize Your Briefings and Debriefings
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
      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. … rather than checklist alone13 Surgical units with strong safety culture yielded significant benefit … Briefings & Debriefings ‹#› AHRQ Safety Program for Surgery – Implementation SAY: A timeout can occur just

1922. PUTTING THE PATIENT BACK IN PATIENT-CENTERED CARE MARCH 30, 2011 (pdf file)
      digital.ahrq.gov/sites/default/files/docs/patient-centered-care-transcript-033011.pdf
      June 16, 2021 - We use a lot of white space, and this is just the basic log-in screen. … I'll just pick up on that, because I think that's a really nice distinction. … TANG: The questioner also asked about privacy, and so I'll build on what someone just said. … CHRISCHILLES: I just wanted to mention, from the standpoint of just medications, we've been very slow … And maybe one just (ph) another question. This one is also for Dr. Chrischilles.

1923. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-facguide.docx
      January 01, 2017 - CUSP is an adaptive intervention that helps teams identify and learn from mistakes, improve safety culture … Putting a new procedure or process in place requires a change in priorities, beliefs, habits, and attitudes … CUSP is designed to improve safety culture and help teams learn from mistakes. … We are saying we need to ensure a safety culture that empowers us to achieve excellence in patient safety … Successful CUSP teams share leadership; they don’t rely just on one person for every project or activity

1924. Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.html
      February 01, 2017 - CUSP is an adaptive intervention that helps teams identify and learn from mistakes, improve safety culture … Putting a new procedure or process in place requires a change in priorities, beliefs, habits, and attitudes … CUSP is designed to improve safety culture and help teams learn from mistakes. … We are saying we need to ensure a safety culture that empowers us to achieve excellence in patient safety … Successful CUSP teams share leadership; they don’t rely just on one person for every project or activity

1925. Creating a Culture of Safety in the Ambulatory Surgery Environment: Implementation Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/implementation.pdf
      May 01, 2017 - CUSP can help ASCs move from a culture in which a punitive response to error prevails to a culture of … CUSP helps ASCs move from a culture in which a punitive response to error prevails to a culture of safety—a … Safety Culture Survey The ASC SOPS can be used to track changes in patient safety culture over time … Assess Your Culture Using the Safety Culture Survey A facility's culture is usually assessed with … continue in your facility so that, over time, people feel that using the checklist effectively “is just

1926. Hard to Swallow | PSNet
      psnet.ahrq.gov/web-mm/hard-swallow
      April 26, 2023 - At a deeper level, physicians need to make sure they do not contribute to a culture in which non-physician … described improving safety as akin to fighting mosquitoes: we have to drain the swamp, rather than just … The institution needs to make sure it does something about the latter, not just the former.

1927. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
      December 01, 2003 - , the most common response is to suspend the clinician(s) involved, pending investigation, in the belief … The Incident Decision Tree supports the aim of creating an open culture, where employees feel able to … the Harvard School of Public Health, explains that a punitive work environment and the widely held belief … incidents that are identified, the employee is suspended from duty, pending investigation, in the belief … Patient safety and the “just culture”: a primer for health care executives.

1928. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49748/psn-pdf
      December 01, 2015 - The case prompted a formal review since the entire hospitalization was deemed preventable given the belief … Therefore, the threshold for performing a diagnostic paracentesis and sending the fluid for culture … receive a thorough evaluation for other evidence of systemic infection, including a urinalysis, blood cultures … I would regard it as potentially predictable and just treat the complication as needed.

1929. Intubation Mishap | PSNet
      psnet.ahrq.gov/web-mm/intubation-mishap
      April 26, 2023 - It´s Not Just What You Say .— How you say something will affect whether the intended recipient understands … communication style and understanding of what others mean by what they say.( 8 ) Communication is not just … are even more susceptible to misinterpretation, due to changing context or differences in gender and culture … and priorities Reactive culture (eg, address problems only when they occur) - Proactive approach … Rethinking surgical safety: more than just a checklist.

1930. 103-How-To-Integrate-Cusp-Approach-Periop-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/103-how-to-integrate-cusp-approach-periop-fg.docx
      April 01, 2025 - This is always a difficult question for teams that are just starting out. … it is important to have a surgeon and nurse from the perioperative setting who are invested in the culture … Just a few members can review interventions and get the plans started! … , implementing independent checks to ensure patients receive appropriate therapies, and fostering a culture … be an exceedingly effective and practical strategy for engaging frontline staff and improving safety culture—while

1931. In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring | PSNet
      psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
      April 26, 2023 - I was interested in the concept of recovering and tolerating incidents and accidents rather than just … Not just purchasing a piece of equipment and installing them, but having goals around what the system … This is not just about technology; it’s also about processes, governance, and education and many other … Those are the actions that you’d be willing to be interrupted for, not just someone with sleep apnea … also positioned as an organizational leader who valued systems engineering, and I think having the culture

1932. In Conversation with…William B. Weeks, MD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
      May 01, 2009 - While there may be some marginal improvement in quality, the cost aspect was just ignored. … So there's a considerable amount of wariness about just saying, "No problem, we'll just reduce our utilization … They just find it in their interest to do that in terms of improving the value of their product. … The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. … Electronic health records: just around the corner? Or over the cliff?

1933. PPE
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/infection-prevention/precautions/ppe-precautions.pptx
      March 01, 2017 - These are just some of the reasons why we want to make sure we're always disinfecting our hands, even … How can you help support a culture of safety around PPE use? … How can you help to support a culture of safety around proper personal protective equipment use? … what elements of a culture of safety can support good habits for PPE use i.e., communication, feedback

1934. What Have We Learned About Safe Inpatient Handovers? | PSNet
      psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
      March 01, 2011 - Our culture in health care is very different from those other industries that have adopted some effective … RW: Difficult because of cultural resistance or difficult because of logistics and the workload just … They're critically unstable and the handoff is more than just temporary in the sense that the team may … So there is a handoff occurring at discharge, and I often think just like you would communicate and sign … We often say handoffs are more than just the transfer of content, it's also the transfer of professional

1935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33813/psn-pdf
      August 01, 2016 - diagnostic terms.(19 ) Clearly, though, the greatest hurdle is to establish a robust patient safety culture … in the dental ecosystem.( 20) As challenging as it has been to establish a safety culture in medicine … Is ambulatory patient safety just like hospital safety, only without the "stat"? … Open wide: looking into the safety culture of dental school clinics. J Dent Educ. 2014;78:745-756.

1936. SOPS® Workplace Safety Supplemental Items for the SOPS Hospital Survey (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/workplace-safety/Workplace-Safety-for-Hospitals-Spanish-12-15-22.docx
      December 01, 2022 - SOPS® Hospital Survey Version 2.0 to help hospitals assess the extent to which their organization’s culture … item set should be added to the end of the SOPS Hospital Survey 2.0, after Section F: Your Hospital, just … Measures: A composite measure is a grouping of two or more survey items that assess the same area of culture … Development, Pilot Study, and Psychometric Analysis of the AHRQ Surveys on Patient Safety Culture™ (SOPS

1937. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33822/psn-pdf
      January 01, 2017 - One of the things that really sharpened my belief about it came when I was first the vice president, … It's just astounding to me that they don't seem to understand the idea of wall-to-wall excellence in … RW: Because the approaches and the culture are essentially the same. PO: Exactly. … That is just unforgivable. … That's just idiocy.

1938. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33678/psn-pdf
      January 01, 2009 - We're only just scratching the surface in this area. … You just went and told the patient what happened. … and ethical duty, and then the implication is that we need to up our quotient of moral courage and just … Patients think this is just human nature—if an error's happened, of course, health care workers might … We know much less about how a patient who has just experienced an adverse event or error would want

1939. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73906/psn-pdf
      October 06, 2021 - Stuebe just described. … Our culture of health, I think, is the most powerful intervention that we have because everything flows … So, we made a lot of noise, and this was not just something unique to our group. … Every single one of those moms just had a baby. … AS: I think I would just want to express my gratitude to AHRQ for funding this kind of work.

1940. 027-Cusp-Program-Sustainability-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/027-cusp-program-sustainability-fg.docx
      April 01, 2025 - essence, sustainability is achieved when the improved processes and interventions are embedded into the culture … CUSP fosters a culture of patient safety by improving patient care through evidence-based interventions … made throughout the safety initiative are maintained over time and embedded into the organization's culture … lower MRSA rates, the team should consider interventions that can be sustained and long lasting, not just … Embedding patient safety into the culture of the unit leads to long-lasting impact and motivation for