Results

Total Results: 3,207 records

Showing results for "just culture".
Users also searched for: just culture

1981. In Conversation with…Thomas H. Gallagher, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
      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 … In many regards, this has been a time-revered risk management belief.

1982. A Costly Colonoscopy Leads to a Delay in Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
      September 01, 2014 - resulting in a 30% copay of $2000, whereas in other developed countries, a basic colonoscopy costs just … Clinicians and health care systems should address this problem systematically, just as they do with other … September 29, 2017 Development of a high-value care culture survey: a modified Delphi … WebM&M Cases Delayed Recognition of a Positive Blood Culture

1983. A National Conference on the Role of Health IT to Improve Medication Management - Q&A (pdf file)
      digital.ahrq.gov/sites/default/files/docs/improve-medication-management-qa-091318.pdf
      September 13, 2018 - It’s taking information about baseline characteristics of a patient – we ask them about their beliefs … their hypertension, the extent to which they think treating hypertension is necessary. their concern beliefs … ANSWER: We are just looking at the data right now. … paramount that we couldn’t see a lot of benefits in the transition setting, then I would say we should just … ANSWER: The pillbox would just detect that the pill had been taken early.

1984. In Conversation with…Vineet Arora, MD, MA | PSNet
      psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
      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

1985. In Conversation With… Andrew Gettinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
      September 01, 2017 - When you ask people why they don't just turn off those "this could happen" alerts, there's a concern … If something comes up and it doesn't make sense, just because the computer presented it to you doesn't … I routinely interact with not just the leadership of ONC but all the various staff members. … I believe everything you just said, but I'm sure some folks out there might say there's an EHR system … As such, another key facet of this work is for organizational leadership to create the blame-free culture

1986. In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
      December 14, 2022 - not only understand what has to be done for patient safety, but are given the time to do it within a culture … Sometimes measures are just slightly different from one program to another. … Some of them were just a little bit different. … There are many lessons here, including communication strategies, culture, leadership, teamwork training … I have a personal belief that if we unleash the voice of the patient in quality reporting, we are going

1987. Measuring Patient Safety | PSNet
      psnet.ahrq.gov/perspective/measuring-patient-safety
      December 14, 2022 - not only understand what has to be done for patient safety, but are given the time to do it within a culture … Sometimes measures are just slightly different from one program to another. … Some of them were just a little bit different. … There are many lessons here, including communication strategies, culture, leadership, teamwork training … I have a personal belief that if we unleash the voice of the patient in quality reporting, we are going

1988. In Conversation With… Paul Aylin, MBChB | PSNet
      psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
      June 01, 2017 - In one hospital I worked at, the microbiologist had to come in to deal with your blood culture. … So, you were encouraged not to do blood cultures on the weekend. … Another suggestion was that maybe it's just that on a Friday you get a different mix of doctors doing … Which I knew before, but this research has just confirmed that. It's been very interesting. … I'm also very interested in not just surveillance at a hospital level, consultant level, or GP level,

1989. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867497/psn-pdf
      February 26, 2025 - placed but did not “see” the retained sponge because they thought the sponge radiopaque markers were just … interventional vascular, cardiac and radiological procedures in sites other than ORs, proceduralists (not just … lieu of counting instruments, although this strategy increases cumulative radiation exposure, not just … in http://www.fda.gov/Safety/MedWatch/ processes of care requires attention to inter-professional culture … determine whether the devices under consideration are likely to be helpful at that site, given that site’s culture

1990. Departure From Central Line Ritual | PSNet
      psnet.ahrq.gov/web-mm/departure-central-line-ritual
      October 13, 2018 - Just then, another trauma patient arrived, and the supervising attending physician left the room. … Here, the safety culture of the operating room (OR) provides us some ideas. … simulation training, these extra eyes may safely be borrowed from the nursing staff—assuming that a culture … July 27, 2022 WebM&M Cases Premature Closure: Was It Just

1991. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49675/psn-pdf
      February 01, 2013 - Her address was correct, but a letter was not sent until 11 days after the culture turned positive. … 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 … By contrast, for the positive vaginal chlamydia culture in this case, a letter would have been an appropriate … Internet phone and address directories could be consulted just as printed ones can be.

1992. 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

1993. 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

1994. CAHPS Moving Forward: Innovations in Tools and Research (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-moving-forward-webcast.pdf
      October 01, 2017 - We have just a few more minutes in this segment, so let me just throw out a couple of questions I think … report better experiences also have employees with more positive perceptions of the patient safety culture … That just seemed implausible. … Cleary, Slide 53 That's just repeating what I just said. … Paul Cleary I'll just say: not enough.

1995. Webinar Transcript - National Quality Strategy Webinar: Using Measurement for Quality Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/workingforquality/events/webinar-using-measurement-for-quality-improvement.html
      November 01, 2016 - So number one, we want to improve support for a culture of safety within provider organizations. … There's a lot of work being done by AHRQ and others to really drive towards changing our culture so it … This has become just a really intense area of focus for us at CMS. … And clinical decision support allows you to get information just as you need it. … So I just want to thank you for that question. I think it's very insightful.

1996. Patient Safety and the Evolution of WebM&M and PSNet | PSNet
      psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
      April 01, 2008 - 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 which errors were … Perspective What We've Learned About Leveraging Leadership and Culture

1997. Making a Case for Organizational Change in Patient Safety Initiatives (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Ramanujam.pdf
      January 01, 2003 - These complex processes, themselves vulnerable to errors, are overlaid on a health care culture that … complex response may require a radical redefinition of an organization’s mission, competencies, and culture … implementation is characterized by inconsistencies, the process can lead to increased skepticism, not just … In some cases, we observed that hospital leaders espouse a blame-free culture, even as nurses who report … As the preceding examples illustrate, better change management capabilities are not just desirable,

1998. 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.

1999. In Conversation With... Freya Spielberg, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
      September 28, 2022 - or populations that just have significant barriers to care. … If we're not going to reimburse, it's just not going to happen. … However, it'll take a change in the culture because we’re so used to the idea that care is provided within … Those people have just been so effective. … Is there a chance that it's the community that just can't support this model of care?

2000. The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? | PSNet
      psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
      June 01, 2017 - In one hospital I worked at, the microbiologist had to come in to deal with your blood culture. … So, you were encouraged not to do blood cultures on the weekend. … Another suggestion was that maybe it's just that on a Friday you get a different mix of doctors doing … Which I knew before, but this research has just confirmed that. It's been very interesting. … I'm also very interested in not just surveillance at a hospital level, consultant level, or GP level,