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1961. EvidenceNow Key Drivers and Change Strategies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/key_drivers_descriptions.pdf
      February 01, 2019 - Practices empower team members by creating a culture that emphasizes collaboration, celebrates each … Everyone in the practice, not just clinicians, may need time to create and adjust to shifts in what … This means more than just paying for conference registrations. … Review measures of implementation and impact of evidence-based practices regularly To create a culture … Create a culture in which all practice members feel comfortable identifying opportunities for quality

1962. 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

1963. SOPS Workplace Safety Pilot Study Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/workplace-safety/workplace_safety_pilotstudyreport.pdf
      November 01, 2021 - Surveys on Patient Safety Culture™ and SOPS® are trademarks of AHRQ. … ™ (SOPS®) Workplace Safety Supplemental Items assess the extent to which the organizational culture … supplemental items were designed to be administered toward the end of the SOPS Hospital Survey 2.0, just … The supplemental items were administered toward the end of the SOPS Hospital Survey, just before the … (a composite measure consists of 2 to 3 survey items that assess the same area of workplace safety culture

1964. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/liability/crane.html
      August 01, 2017 - Each reported error was coded with just one primary error but with up to four additional associated or … Practice Safety Culture Staff Opinions About Office Safety Culture Percent With Positive Response … Source: 2010 Preliminary Comparative Results: Medical Office Survey on Patient Safety Culture. … near-miss reporting and process improvement appeared to lead to positive changes in culture. … A subsequent study should track individual staff assessments of culture over time.

1965. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer | PSNet
      psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
      February 26, 2025 - In fact, the success of the ASN has instilled a culture of innovation within the local hospital system … Establish a just culture framework and ensure buy-in from all partners. … Engage just culture principles and transform thinking from a root-cause analysis framework to a systems-focused

1966. Advancing Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advancing/index.html
      July 01, 2022 - The IOM noted that many of the errors in health care result from a culture and system that is fragmented … weeks of the release of the To Err is Human report . 2000 Setting a Direction In early 2000, just … Aviation and other high-risk industries were well aware that organizational leadership shapes culture … the Hospital Survey on Patient Safety Culture , a psychometrically tested and well-received survey … It focused further on reporting systems, risk assessment, safety culture, clinical process improvement

1967. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
      January 01, 2010 - The IOM noted that many of the errors in health care result from a culture and system that is fragmented … of Evidence, Design, and Implementation 2000 2001 2000 Setting a Direction In early 2000, just … Aviation and other high-risk industries were well aware that organizational leadership shapes culture … To assist organizations and their units in improving patient safety culture, AHRQ developed and … released the Hospital Survey on Patient Safety Culture (www.ahrq.gov/qual/patientsafetycul ture

1968. Final Progress Report: Development of a toolkit for dissemination and implementation of the OR crisis checklists (pdf file)
      www.ahrq.gov/sites/default/files/2024-05/berry2-report.pdf
      January 01, 2024 - both the contextual factors present prior to implementation (e.g., structural factors, patient safety culture … toolkit that outlines methods of building an implementation team, adapting the checklist to local culture … So I think the first thing I would say is, absolutely locally customize, absolutely know your own culture … To remove that barrier, the culture of a facility would have to change to a place in which use of cognitive … Identifying organizational cultures that promote patient safety.

1969. Tip 1. In a Quality Report, Write Text That’s Easy To Understand | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/resources/writing/tip1.html
      May 01, 2015 - Acronyms It takes extra effort for readers to learn and remember a new acronym, so don’t use acronyms just

1970. 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

1971. Patient Safety Research in Medical Group Practices: Measurement and Data Challenges (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
      December 01, 2004 - care adverse events originate in the ambulatory care sector.1–3 The magnitude of these events is just … field has been slow to develop.24 Moreover, there is concern that the instruments used to measure cultures … While this is a valid first step in assessing practice cultures, the next important step is to measure … the degree of clinician agreement on the culture. … Measuring the culture of medical group practices.

1972. 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.

1973. In Conversation With… David Blumenthal, MD, MPP | PSNet
      psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
      July 01, 2012 - It was not possible given our size, political culture, and political institutions. … Clinicians will just be talking to their patients and the whole thing will be recorded, synthesized, … We just have to be careful in trying to predict the future. This is moving so fast. … Our current policy is based on the belief that anything that encourages the purchase and use of health … This belief that health IT, by itself, improves care and reduces costs has not only diminished government

1974. Patient Safety and Health Information Technology: Learning from Our Mistakes | PSNet
      psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
      July 01, 2012 - Our current policy is based on the belief that anything that encourages the purchase and use of health … This belief that health IT, by itself, improves care and reduces costs has not only diminished government … It was not possible given our size, political culture, and political institutions. … Clinicians will just be talking to their patients and the whole thing will be recorded, synthesized, … We just have to be careful in trying to predict the future. This is moving so fast.

1975. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50393/psn-pdf
      September 01, 2019 - 1999 To Err Is Human report, there was a recognition that preventing harm would require more than just … sciences, achieving progress requires an understanding of human behavior, the sociology of teams, and the culture … Traditional medical culture largely consisted of a "blame and shame" atmosphere—one in https://psnet.ahrq.gov

1976. Chapter 1: Introduction (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/iomracereport/reldata1a.html
      April 01, 2018 - Quality care can depend on a provider's identification and understanding of the cultural beliefs and … for moving forward with standardized data collection across all health and health care entities, not just … Measure of race, ethnicity and culture: Population science isn't science unless you know the population … Variation in asthma beliefs and practices among mainland Puerto Ricans, Mexican-Americans, Mexicans and

1977. 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

1978. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications | PSNet
      psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
      February 01, 2004 - Her address was correct, but a letter was not sent until 11 days after the culture turned positive. … study of three specific laboratory tests obtained in an ED (one of which, like this case, was chlamydia cultures … If blood cultures drawn in an ED turn positive after the patient has been discharged, for example, a … Internet phone and address directories could be consulted just as printed ones can be. … WebM&M Cases Delayed Recognition of a Positive Blood Culture

1979. 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

1980. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49460/psn-pdf
      September 01, 2004 - Rather, just as medical errors have complicated causes, HIPAA is a complex medico-legal matter, which … Indeed, reporting errors is one of the few ways that my classmates, often just onlookers, have actually … On the culture of student abuse in medical school. Acad Med. 1998;73:1149-58.[ go to PubMed ] 3.