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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.
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - The concept of just culture , now widely used in health care, emphasizes that most errors result from … Further aspects of this issue are discussed in the Culture of Safety Primer and in a 2024 Perspective … focus on enhancing patient and caregiver engagement, tracking and sharing safety data, promoting a culture
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digital.ahrq.gov/sites/default/files/docs/reducing-provider-burden-slides-012518.pdf
January 25, 2018 - support VTE prophylaxis
• But…
ØUsability, usefulness and workflow integration of health IT
ØNot just … Organizational culture
8. Workload
9. Technology access
10. Environment
11. … Organizational culture
8. Workload
9. Technology access
10. Environment
11. … Organizational culture
8. Workload
9. Technology access
10. Environment
11. … Organizational culture
8. Workload
9. Technology access
10. Environment
11.
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psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - organizations can use to prevent these errors include teamwork training and efforts to
improve the culture … An organizational culture of
safety promotes teamwork and standard practice using the Glucommander and … glycemic control and monitor the processes that
support good outcomes, including those related to culture … Glucommander use
Lack of an institutional standard of
care for inpatient glycemic control
Routine and just-in-time
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/workplace-safety/Workplace-Safety-Hospitals-2022-1215-SPANISH-508.pdf
January 01, 2022 - SOPS® Hospital Survey Version 2.0 to
help hospitals assess the extent to which their organization’s culture … item set should be added to the end of the SOPS Hospital Survey 2.0, after Section
F: Your Hospital, just … Measures: A composite measure is a grouping of two or more survey items that assess the same area
of culture … Development, Pilot Study, and Psychometric
Analysis of the AHRQ Surveys on Patient Safety Culture™
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - Is this just a case of an overzealous charge nurse upset with two colleagues who violated "protocol" … Since no apparent difficulties usually arise, the provider culture has come to "normalize" these informal … Systems approaches to prevent this type of error in the future center on the "safety culture. … Promoting a culture of safety. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds.
-
psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - Let me
just give you a couple of examples of the new way we're thinking at IHI about safety. … burnout, particularly people feeling like they have been
working very hard at these things and it's just … MB: To me good leadership understands the difference between the two circumstances you just described … In other
words, the culture and context matter, the leaders matter, and the mechanism is the change … Hence, the theory was that if you
understood your culture and you had a mechanism that you could try
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
January 01, 2005 - This typically occurs in organizations that have a “blaming” culture
when errors occur. … Because FDA can have little effect on the reporting culture of a facility,
attention was focused on … News, view transcripts and slide shows from past Clinical Engineering
Audio-Conferences, and search a custom … They don’t report the
catheter that breaks—they just get another one. … the
organization’s systems are really at the root of the problem, and c) clinicians
report they are just
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide2.html
February 01, 2016 - And while medical staff in many hospitals embrace a culture of teamwork and standardization, this is … It is often just as important to figure out what parts of the guidelines not to address as it is to
-
www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide2.html
February 01, 2016 - And while medical staff in many hospitals embrace a culture of teamwork and standardization, this is … It is often just as important to figure out what parts of the guidelines not to address as it is to
-
www.ahrq.gov/research/findings/factsheets/minority/cbprbrief/index.html
April 01, 2020 - and conduct of the research study by:
Bringing community members into the study as partners, not just … Health Caucus This group, affiliated with the American Public Health Association, is guided by the belief
-
www.ahrq.gov/sites/default/files/publications/files/cbprbrief.pdf
January 01, 2014 - and conduct of
the research study by:
• Bringing community members into
the study as partners, not just … Health
Caucus
This group, affiliated with the
American Public Health Association, is
guided by the belief
-
psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - It´s Not Just What You Say. … communication style and understanding of what others mean by what they say.(8)
Communication is not just … are even more susceptible to misinterpretation, due to changing context or
differences in gender and culture … could limit staff
training time)
B
Goals, policies, and standards Probably not a factor -
Safety culture … and priorities
Reactive culture (eg, address problems only when they
occur) - Proactive approach would
-
integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/what-not-do
June 01, 2022 - Obtain Behavioral Health Expertise and Build a Culture of Integration
Don’t assume that every behavioral … Don’t just “plunk” a behavioral health provider into a practice.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-ve-supp-item-set-08-2022.docx
January 01, 2022 - item set should be added to the end of the SOPS Hospital Survey 2.0, after Section F: Your Hospital, just … Measures: A composite measure is a grouping of two or more survey items that assess the same area of culture
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/spot-coaching.pdf
April 01, 2022 - bloodstream
infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) and improve safety culture … • Telling seems faster—In busy units, it seems faster to just tell someone how to behave or what
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-ve-suppl-item-set-spanish-2023.docx
January 01, 2023 - set should be added to the end of the SOPS Medical Office Survey, after Section G: Overall Ratings, just … Measures: A composite measure is a grouping of two or more survey items that assess the same area of culture
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod2sess1.html
October 01, 2014 - Often, changes can be detected just because you notice something out of the ordinary. … Cultural differences —These can be our beliefs about other groups of people, our values, or what we think … Culture.
Status.
Interpersonal issues.
Environmental or system barriers.
-
psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - You cannot just stick something new in the clinical workflow and expect it to work. … It is not enough just to say we are engaging the patient; we must be able to measure that. … prevention strategies integrated into the day-to-day workflow, leadership support and an organizational culture … One study examined the association between nursing unit safety culture, quality of care, nurse staffing … levels, and inpatient falls; the researchers found that nursing units with strong safety culture and
-
psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - prevention strategies integrated into the day-to-day workflow, leadership support and an organizational culture … One study examined the association between nursing unit safety culture, quality of care, nurse staffing … levels, and inpatient falls; the researchers found that nursing units with strong safety culture and … You cannot just stick something new in the clinical workflow and expect it to work. … It is not enough just to say we are engaging the patient; we must be able to measure that.