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1921. 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.

1922. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33686/psn-pdf
      August 01, 2009 - And they went from 19 deaths out of 1750 patients with central lines, down to a handful in just a few … Is that an important difference between health care and industry in trying to create a culture that … It was a unionized plant, still UAW, but the union grievances against management just disappeared. … I just don't think we have figured out how. … Let's not just write off the whole project.

1923. 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.

1924. 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.

1925. 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

1926. 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.

1927. 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.

1928. 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.

1929. 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

1930. AHRQ Nursing Home Survey on Patient Safety Culture: User’s Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/nursing-home/nursinghome-users-guide.pdf
      April 01, 2022 - CULTURE: USER’S GUIDE PATIENT SAFETY AHRQ Nursing Home Survey on Patient Safety Culture: User’ … Patient safety culture refers to the beliefs, values, and norms shared by healthcare practitioners and … Definition of Patient Safety Culture Nursing Home Survey on Patient Safety Culture User’s Guide 2 … Adding Supplemental or Custom Items If your nursing home wants to add items to the survey, add these … just before the background items (after Section E and before Background questions).

1931. Personal Health Literacy | PSNet
      psnet.ahrq.gov/primer/personal-health-literacy
      October 31, 2023 - Health literacy is affected by many factors, including socioeconomic status, culture, and language. 11 … improvement program if they teach the underlying skills needed to manage health or obtain healthcare, and not just … October 28, 2020 Use of simulation to measure the effects of just-in-time information … October 5, 2022 WebM&M Cases Culture Clash No More: Integration

1932. In Conversation With… Beverley H. Johnson | PSNet
      psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
      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

1933. 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

1934. 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

1935. In Conversation With... Heidi Wald, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-heidi-wald-md
      November 26, 2019 - Heidi Wald: It started just after residency, when I joined a hospitalist program. … The Institute of Medicine’s report on medical errors [1999] had just come out and that really influenced … And not just skill set, but also who has the time? Are CNA’s the right people to walk the patients? … It’s not just the single medication that’s the problem – it’s the combination of side effects. … In addition to patient safety programs and the development of patient safety culture, we also tie in

1936. In Conversation with…Pat Croskerry, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
      June 01, 2010 - PC: Just the way that people get set up for errors. … It never amounts to anything; she's just a frequent flyer." For me, those are red flags. … I make mistakes just like the next guy, but hopefully I'm making fewer because I see them coming. … One thing you can do is just take a time out and excuse yourself and say "I just have to attend to something … How did you get the culture to accept that? PC: It wasn't easy.

1937. In Conversation with... Charles Ornstein | PSNet
      psnet.ahrq.gov/perspective/conversation-charles-ornstein
      October 01, 2009 - There's a real range of knowledge about health care, about medical mistakes in particular, but also just … You probably spend a lot of time on the phone just making sure that you have the basics and that you … Is the goal to make it better or at some point do you just say this is not going to happen? … If anything, they seemed to just get worse over time. … understood that health care could cause harm, this concern was too inchoate to generate real change in the culture

1938. 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

1939. Improving Communication and Teamwork Around Antibiotic Decision Making (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/communication-facilitator-guide.pdf
      November 01, 2019 - Communication and Teamwork SAY: Communication and teamwork are two key elements of patient safety culture … Sputum Gram stain and cultures as well as blood cultures are negative, but his creatinine has increased … ’s ridiculous—why do you want to keep giving the patient antibiotics that are hurting his kidneys just … Since his cultures don’t show MRSA or Pseudomonas, I think it would be reasonable to stop the vancomycin … Sputum Gram stain is negative and cultures grow normal respiratory flora.

1940. In Conversation With… John D. Birkmeyer, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
      January 31, 2024 - We studied measurable aspects of safety culture and communication and teamwork in the operating room. … Just by chance some of the earliest videos that came in happened to be from surgeons that were really … the front end or which outcome or aspect of quality we evaluated on the back end, the correlation was just … The hypothesis of that study is that we can make the really good surgeons just a little bit better, we … What struck me about the data was just how remarkable even an untrained eye can be in identifying who's