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1961. 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

1962. 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

1963. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/handout.html
      November 01, 2017 - Just a few months ago, we started attending the care plan reviews as well. … This was not always so easy here but we have worked hard to implement TeamSTEPPS and the culture of our … Facilitator: It’s wonderful to hear about such a change in facility culture, Joanie [DON]. … She just had her baby, so she will be out several more weeks. … Falls prevention is not just a nursing concern.

1964. Fallspximpl-Handouts (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.docx
      June 02, 2025 - Just a few months ago, we started attending the care plan reviews as well. … This was not always so easy here but we have worked hard to implement TeamSTEPPS and the culture of our … Facilitator: It’s wonderful to hear about such a change in facility culture, Joanie [DON]. … She just had her baby, so she will be out several more weeks. … Falls prevention is not just a nursing concern.

1965. Building an Engaged CUSP Team Facilitator Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-team-notes.docx
      April 01, 2022 - Support from the top is crucial to the success of culture improvement efforts, but real, lasting change … Improving culture within the healthcare setting requires the model to be based on the understanding that … all culture is local and that work to reform culture must be owned at the local unit level. … and culture issues are best examined and improved at the level of the individual unit. … This type of rounding is a great way to engage with all frontline staff (and not just the senior executive

1966. 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.

1967. Final Progress Report: Detection, Education, Research, and Decolonization without Isolation in Long-term Care (DERAIL MRSA) (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/peterson-report.pdf
      January 01, 2025 - Secondary outcomes included the number of MRSA infections, positive MRSA clinical cultures, antimicrobial … number of 63 culture positive body sites. … #2 Number of cultures tested 137 98 308 195 462 305 Positive Confirmed MRSA tests 34 16 37 29 60 14 … Culture prevalence 24.82% 16.33% 12.01% 14.87% 12.99% 4.59% LTCF #3 Number of cultures tested 115 176 … There is a great need to perform well-designed demonstration projects in the LTCF, such as this one just

1968. 130-Ss-Swiss-Cheese-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
      April 01, 2025 - Individual provider responsibility is just one level of this system. … It is just as essential to learn from defects that cannot be prevented. … His sternal wound culture came back positive for MRSA. He was in the hospital for 5 extra days. … day of surgery, when the pre-op holding area nurse had asked if his decolonization was completed, he just

1969. 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

1970. Factors that Impact Perinatal Care Experience and Outcomes: Slide Presentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/perinatal-care-experience-slides.pdf
      March 06, 2025 - Science University) Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture … Presentation 1 Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture … Environment Effective, Timely, Quality Care Safety Communication and Accountability Respect for Culture … Examples of clinician influences: Training, clinical experiences, colleagues, personality, clinical culture … scalable approach to improving postpartum health and wellbeing  Very few no-shows and scheduling took just

1971. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Teamwork and Leadership (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-teamwork-leadership.pdf
      April 30, 2025 - of collaborative clinical culture that can be used in future research. … Church, Virginia 05-336R-03 [Interagency Agreement] Team Training Curriculum (TeamSTEPPS) and Just … Curriculum (TeamSTEPPS) and Just Culture toolkits. … Church, Virginia 06-336R-03 [Interagency Agreement] Team Training Curriculum (TeamSTEPPS) and Just … Curriculum (TeamSTEPPS) and Just Culture toolkits.

1972. Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2020 User Database Report Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2020_MOSOPS_Part_I-rev0921.pdf
      January 01, 2020 - Surveys on Patient Safety Culture™ and SOPS™ are trademarks of AHRQ. … refers to the beliefs, values, and norms shared by staff throughout the organization that influence … Patient safety culture is the extent to which these beliefs, values, and norms support and promote patient … (F3R) 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.

1973. Final Progress Report: Simulation Training For Rapid Assessment And Improved Teamwork (STRAIT) (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/weinger-report.pdf
      January 01, 2024 - STRAIT utilized hybrid simulation techniques (e.g., high-fidelity manikins as the just emerging patient … Communication Culture Survey We administered a communication culture survey to all anesthesia providers … Data Analysis–Communication Culture Survey (CCS) The Communication Culture Survey is a 14-item instrument … Lessons learned will guide our and others’ development of simulation-based curricula, not just for handovers … The OR culture scores did not increase as much.

1974. 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

1975. Appendix A, Pt. 3 | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/stpra/stpraapa3.html
      April 01, 2018 - CHG no-rinse cloths to do a site-specific wash on the night before surgery and in the holding area just … Staphylococcus aureus in pure or mixed culture accounted for 50% of the infections. … clean wounds developed surgical wound infection. 10 of the 14 surgical wound infections grew positive cultures … The patients with mild perioperative hypothermia had three times as many culture-positive surgical-wound … days after surgery should not significantly increase surgical morbidity, whereas large doses given just

1976. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet
      psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
      July 22, 2020 - Creating a culture of safety that values transparency, continuous learning, and a systematic approach … Approaches to Improving Patient Safety Adopt and maintain a safety culture Medication safety involves … A perception of poor safety culture has been linked to increased error rates. 10 Broadening awareness … In a strong safety culture, error prevention and recovery programs are well developed, updated regularly … Program assessment and error investigation should consider a “just culture” approach that includes non-punitive

1977. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK3_T5-Minimum_Criteria_for_3_Infections_Training_Slides-final.pptx
      October 01, 2016 - Some areas we will just touch upon; for others, we will go into greater depth. … These are just some examples. … And, just a little history: SBAR originated in the U.S. … Studies have shown that a positive culture obtained solely because of a change in urine appearance will … Just like before, fill out everything as appropriate. What is purulent drainage?

1978. 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

1979. 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

1980. Module 5: Resident and Family Engagement: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module5/mod5-facguide.html
      March 01, 2017 - listen to and honor resident perspectives and choices, resident and family makeup, knowledge, values, beliefs … , and religious and cultural background. … The culture at a person-centered facility promotes the philosophy that each person has the opportunity … in identifying resident and family advisers should consider asking advisers who represent different cultures … They provide constructive feedback, and focus on how to prevent a problem from reoccurring rather than just