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2021. 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.

2022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49723/psn-pdf
      January 01, 2015 - Appreciate the importance of safety culture on labor and delivery units. … When asked about the incident, they both replied that they "just didn't see the bad tracings" and commented … , in our experience, a major factor contributing to interpretation of FHR is related to the safety culture … near-misses and poor outcomes is also an essential step towards building a safer system and a safety culture … Improving communication on the labor and delivery unit and establishing an ultrasafe and resilient culture

2023. AHRQ Safety Program for MRSA Prevention
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/008-antibiotic-stewardship-slides.pptx
      October 01, 2022 - Prevention | ICU & Non-ICU Antibiotic Stewardship Fundamental Best Practices Antibiotic Stewardship Blood Culture … Have I ordered appropriate cultures before starting antibiotics? … , negative blood cultures. … Why do you want to keep giving the patient antibiotics that are hurting his kidneys just because you’ … Since his cultures don’t show MRSA or Pseudomonas, I think it would be reasonable to stop the vancomycin

2024. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49591/psn-pdf
      October 01, 2009 - Describe characteristics of a culture that encourages open communication, respect, and opportunities … Organizations that aspire to create cultures of safety must address the pervasive behavioral patterns … Development of a culture such as this, however, requires more than role-modeling. … Just as the staff nurse needs to learn to speak up to defend patient safety, so too does the effective … Behaviors that undermine a culture of safety. Sentinel Event Alert. July 9, 2008.

2025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851389/psn-pdf
      July 31, 2023 - 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

2026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33617/psn-pdf
      August 01, 2005 - Is it that there's not enough money, or that the culture is not one that promotes recruiting and retaining … We just believe that the people who are best able to determine what each unit needs are those who are … Finally, we need a culture in which safety is considered a problem-solving situation and not a punishment

2027. Final Progress Report: The PeaceHealth Community-wide Electronic Shared Medication List (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/stock-easton-report.pdf
      January 01, 2024 - safety culture survey. … There was a strong belief that safer medication practices in the ambulatory setting will lead to fewer … leadership, who felt that medication reconciliation needed to occur across all care settings, not just … public-private relationships are formed, and implementation occurs in systems of care that have different cultures … Staff Engagement and a Culture of Safety.

2028. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet
      psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
      August 28, 2024 - For us, it’s not just about event management; it’s about how we can incorporate Safety-II principles … However, as we shift our culture, we have also shifted to referring to great catches and patient care … I also had a mistaken belief that regulatory bodies would insist that you've done an RCA. … Some organizations just ask, What is one thing you do to keep your patient safe? … This is safety culture transformation at the organizational level and an important overall strategy for

2029. Application of Safety-II Principles | PSNet
      psnet.ahrq.gov/perspective/application-safety-ii-principles
      August 28, 2024 - For us, it’s not just about event management; it’s about how we can incorporate Safety-II principles … However, as we shift our culture, we have also shifted to referring to great catches and patient care … I also had a mistaken belief that regulatory bodies would insist that you've done an RCA. … Some organizations just ask, What is one thing you do to keep your patient safe? … This is safety culture transformation at the organizational level and an important overall strategy for

2030. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33842/psn-pdf
      January 01, 2018 - The best approach to both understanding and resolving them is sociotechnical, which includes not just … retirements, organizational leadership changes, CDS failures (14), and hardware failures (15), to name just … contingency planning for downtime and system configuration).(16) Lesson Two: EHR Safety Requires More Than Just … As such, another key facet of this work is for organizational leadership to create the blame-free culture

2031. Medication Monitoring for Vulnerable Populations via IT (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017018-lehmann-final-report-2010.pdf
      January 01, 2010 - the ambulatory setting, using a set of national consensus measures and identify the organizational culture … rolled-up versions of reports of quality measure data as useful, could not be tested as there are just … Averaged responses tended to be just above the neutral midpoint and were consistent over time. … for attitudes about usefulness and for whether the full list of overdue patients was provided or just … Provider‐related factors may include a lack of awareness that medication monitoring is indicated or a lack of belief

2032. Slippery Slide Into Life | PSNet
      psnet.ahrq.gov/web-mm/slippery-slide-life
      January 21, 2017 - Deficiencies in organizational culture (hierarchy and intimidation, failure to function as a team, and … Simulation-based training is not just for novices. … currently no true neonatal human patient simulator available on the market; all “infant” simulators are just … Culture change and resource acquisition require the cooperation of those controlling people, space and … June 1, 2016 Building a culture of safety in ophthalmology.

2033. 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.

2034. Improving the Measurement of Surgical Site Infection Risk Stratification and Outcome Detection
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/ssi/ssiapu.pptx
      September 18, 2011 - Maximum post-operative leukocyte count is not less than 7.78 Absence of a post-operative culture … Total Knee Arthroplasty: Either of the following: Presence of a post-operative culture … than 3mg/dL, or Any post-operative antibiotics given, or Presence of a post-operative culture … in-garbage out phenomenon Risk stratification models should weigh relative contribution of each risk, not just … Cx_Site_Matchinteger for example culture site hip for hip operation Re_Admitinteger readmission on postop

2035. 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.

2036. Patient Engagement and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
      February 01, 2013 - In just the past few months, the Commonwealth Fund reported a striking degree of international variation … 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 … 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

2037. Strategies To Support Staff | The Academy
      integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/obtain-training-and-support-providers-and-staff/strategies-support-staff
      January 01, 2019 - Sometimes, it can be just as beneficial for practices starting MAT to find other programs or providers … This model can help create a collaborative culture and strengthen relationships between providers. … Started Understanding the Components of MAT Addressing Organizational Readiness and Culture

2038. TeamSTEPPS Team Leadership Module 2
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-2-slides.pptx
      June 02, 2025 - Support and encourage staff during implementation and culture change. … Define the culture of the organization. 15 15 Team Structure Video Team Leadership 16 … equipment is sometimes missing or not functioning properly, and the lead trauma physician often shows up just

2039. Hospital Survey on Patient Safety (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
      June 02, 2025 - · For the survey items grouped according to the safety culture composites they are intended to measure … read the Items and Composites document. · To participate in the AHRQ Hospital Survey on Patient Safety Culture … It is just by chance that more serious mistakes don’t happen around here (1 (2 (3 (4 (5 11.

2040. Hospital Survey on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
      June 02, 2025 - • For the survey items grouped according to the safety culture composites they are intended to … • To participate in the AHRQ Hospital Survey on Patient Safety Culture Comparative Database, the … It is just by chance that more serious mistakes don’t happen around here .........................