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2061. Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
      January 01, 2010 - Blood cultures and urine cultures grow Escherichia coli and he is diagnosed with CAUTI and septicemia … The overall culture of an emergency department can challenge or enhance good clinical decision-making … In many cases it is not just the UTI that is avoided, but risk of urosepsis is also avoided. … Administrative support Nurse-physician relationships Practice culture The take home Clinical decision-making … Cardiology) ED Workflow and Culture & Urinary Catheter Placement ED workflow requires physicians

2062. Standardized Nursing Protocol: Basin Bed Bathing With 2% Liquid CHG and Showering With 4% CHG Liquid Soap (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-chg-bed-bathing.docx
      March 01, 2022 - positive methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) cultures … Note: Cloths should not be removed from warmer until just before bath. · For obese or incontinent patients … Remind patient that skin may feel sticky for just a few minutes after 2% CHG impregnated cloths are applied

2063. Strategies for Improving Patient Experience with Ambulatory Care: Tools to Help Patients Communicate Their Needs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/communication/cahps-strategy-section-6-h.pdf
      July 07, 2017 - One issue is that many, if not most, patients are just beginning to become comfortable with relationships … shift is especially difficult for older patients and people who do not speak English or who come from cultures … For example, just prior to a doctor visit, a nurse may interview the patient, review the chart together

2064. Incorporating Health IT Into Workflow Redesign: Request for Information Summary Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/workflowredesignrfi.pdf
      July 01, 2010 - These use cases can be used to build a custom application or can be used to evaluate product solutions … Now it’s just a number on the computer screen of things to be done. … Now I just get the lab papers; I have to pull up the chart in the EMR. … These use cases can be used to build a custom application or can be used to evaluate product solutions … Just what the doctor ordered.

2065. Improving Anxiety Detection in Pediatrics Using Health Information Technology - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs024314-bauer-final-report-2018.pdf
      January 01, 2018 - automates surveillance and screening for preventive and disease management with pre-screening items, just … In addition, a family friendly one page JUST IN TIME handout is available to print and provide the family … referral for mental health was made, whether medication was initiated, and whether the respective JUST … Additional considerations raised was the content of the JUST IN TIME (JIT) handout, specifically for … Similar discussions about the JUST IN TIME handout for ADHD were also reviewed at the CHUGs and the

2066. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
      April 20, 2004 - Use of the BCMA software ceased in November 2000, just 8 months after its implementation. … and helped to answer the question asked of any pharmacist: “If you knew that a critical patient had just … where the “two-challenge rule” is practiced— is essential to the growth of an institutional safety culture … : “Designing systems for safety requires specific, clear, and consistent efforts to develop a work culture … It is also necessary for organizational leadership to promote and endorse a culture of support during

2067. AHRQ-Funded Patient Safety Project Highlights (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-pfe.pdf
      January 01, 2023 - Patient Advocacy Reporting System (PARS) promoted professional self-governance, fostered a fair and just … and knowledge needed to effectively incorporate patient and family engagement approaches into their cultures … implement an intervention process that promotes professional self- governance, fosters a fair and just … culture of safety and kindness, and reduces avoidable lawsuit risk. … It showed that physicians were not good judges of patients’ health beliefs.

2068. Final Progress Report: Technology To Improve Medication Safety in Nursing Homes (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
      January 01, 2024 - Although our primary outcome measures do not reflect the impact of what appeared to be changing cultures … Moving from a culture of blame to a culture of safety in the nursing home setting. … A just culture: The role of nursing leadership. J Nurs Care Qual 2007; 22(3), 210-212. … A just culture: The role of nursing Book Chapters and Other Scholarly Works Presentations Vogelsmeier … Moving from a culture of blame to a culture of safety in the nursing home setting.

2069. 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.

2070. In Conversation With… Christopher P. Landrigan, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
      April 01, 2013 - There is no way to enforce someone sleeping just because they are provided with time off work. … Just as we would expect our colleagues not to show up to work drunk, we should expect them to show up … : Well, the ACGME certainly had it right that this is a complicated thing to do and that you can't just … This means that the local context (not just the schedules but the quality of the residents, the culture … Do certain schedules, or other matters of culture, information technology, and leadership, lead to better

2071. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit | PSNet
      psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
      December 01, 2012 - successfully implemented within quality improvement programs and routine clinical care.( 7,8 ) It is our belief … Then I just never stopped. … They may be having an MI and just present with the mental status change. … It's just as you know, a very, very slow process. … August 4, 2021 Organisational culture: variation across hospitals and connection to patient

2072. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
      January 01, 2021 - within each type of gauze material runs throughout the dressing, whereas on the right, the marker is just … training is provided by hospitals for nurses working on obstetric or gynecology units — Hospital culture … The organizational culture should encourage health care providers to communicate and collaborate with

2073. Team Training: Classroom Training vs. High-Fidelity Simulation | PSNet
      psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
      January 12, 2011 - Alternatively, they may practice conflict resolution or other strategies to improve the culture of safety … direct costs for us to train our staff of more than 200 people would have been more than $85,000 for just … single intervention, either classroom or simulator-based, is likely to effect a permanent change in the culture … Rather, team training in these environments must create a structure and a culture that encourage the … Providers Health Care Executives and Administrators Educators Communication between Providers Culture

2074. Bowel Injury After Laparoscopic Surgery | PSNet
      psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
      January 19, 2016 - postoperative outcomes.( 9,10 ) A system that emphasizes the importance of non-technical skills and an overall culture … An organizational culture that emphasizes safety will work to flatten hierarchies, so that junior residents … Strong leadership will promote a culture wherein senior surgeons are kept informed about the status of … In many institutions, creating this kind of culture will require formal training in effective behaviors … Protocol-based care is associated with not just shorter hospital stays but also a lower incidence of

2075. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
      August 01, 2022 - The CANDOR process embraces Just Culture principles, which recognize that "active" errors represent predictable … Statements include: "I was questioning myself over and over again… but then I thought… I've just had … what to do, interrogating or questioning another person, judging another person, imposing one's own beliefs … incident in perspective, and focusing on the second-victim's feelings and reactions to the event, not just

2076. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49497/psn-pdf
      December 01, 2005 - 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

2077. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.pdf
      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 … 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.

2078. Safe Medication Administration: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
      July 01, 2023 - used on L&D units, but administration procedures vary greatly due to lack of standardization, local culture … Have "just in time" crucial conversations. … used on L&D units, but administration procedures vary greatly due to lack of standardization, local culture

2079. Mutual Support: Severe Hypertension (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
      July 01, 2023 - is a key element in being a good team member, even when it’s sometimes difficult to do because the culture … Patients might be instructed to use the same power words we just described. … Just try a few moreJust try a few more times… I am sure you will get it. … It can be just as difficult to give as it is to receive feedback. … Finally, DESCR is a great tool to help reinforce and establish a culture of huddles for high‐risk patients

2080. Mutual Support: Severe Hypertension - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support.pptx
      July 01, 2023 - is a key element in being a good team member, even when it’s sometimes difficult to do because the culture … Patients might be instructed to use the same power words we just described. … Just try a few more times… I am sure you will get it. … It can be just as difficult to give as it is to receive feedback. … Finally, DESCR is a great tool to help reinforce and establish a culture of huddles for high-risk patients