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2141. In Conversation With… Didier Pittet, MD, MS | PSNet
      psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
      May 01, 2014 - We spoke with him about hand hygiene in health care, including how to implement culture change and measure … Whether to build in incentives or just use pride and shame and some level of public reporting? … You will realize that from performance monitoring, that education and institutional safety culture have … An important point is to realize that we need to adapt this strategy to different cultures and different … Sometimes people look at hand hygiene and say, it should just be required.

2142. Partnering to Improve Patient Safety in Rural WV - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs014920-bellamy-final-report-2007.pdf
      January 01, 2007 - Patient Safety Culture Survey: The AHRQ Hospital Survey on Patient Safety Culture was distributed … Critical Access Hospitals represented just over half (~56%) of the participating hospitals and half … Getting the Most Out of the AHRQ Hospital Survey on Patient Safety Culture. … Using the AHRQ Hospital Survey on Patient Safety Culture – Lessons Learned. … “Patient Safety Culture in CAHs: How CAHs Compared to AHRQ Benchmarks.”

2143. Security Lapse | PSNet
      psnet.ahrq.gov/web-mm/security-lapse
      December 18, 2019 - 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.

2144. In Conversation With… Matthew Weinger, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
      August 01, 2018 - MW : It's probably both, but I think there just is not a lot of money in health care education. … Some other countries do more simulation, but there's a fundamental cultural belief that's still hard … Contrast that with nuclear power, where a safety culture is imposed in part by the regulators and in … Two other advances that we're just beginning to see are going to be really exciting. … We're just starting to see this technology.

2145. Using Health IT Chronic Disease Management (pdf file)
      digital.ahrq.gov/sites/default/files/docs/hit-cdm-transcript-062111.pdf
      June 16, 2021 - Just a word here we did retrain the staff in taking blood pressure. … Here this is just a dummy report. … First is Open Door offered a culture of quality improvement, and supported learning, and change. … And I would just say this is probably a generalizable lesson. … really challenged just to meet the daily needs of the patient.

2146. Clean Equipment and Environment Promotes Safe Resident Care | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/environment-and-equipment/environ-equip-slides.html
      March 01, 2017 - Disinfect port with alcohol swab for 15 seconds before obtaining a urine culture. … Just Clean Your Hands educational resources. Ontario Agency for Health Protection and Promotion . … Just Clean Your Hands educational resources. Ontario Agency for Health Protection and Promotion .

2147. Quality Improvement in Action Facilitator Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/qi-action-notes.docx
      April 01, 2022 - Other gaps identified in the unit are a lack of a CLABSI and CAUTI champion, unit culture, and senior … Culture shapes behavior on the job, but it also can improve outcomes. … Are reasons true indications or unit culture? … and behavioral changes as well as to garner belief among staff members that they can make a difference … consistently done · Central line dwell times average over 12 days, and most staff report leaving lines in “just

2148. The Mobile Mock Operating Room: Bringing Team Training to the Point of Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Paige_6.pdf
      January 24, 2008 - Thus, the MMOR was assigned to an OR, just as actual cases were assigned. … Participants scheduled for training were then assigned to the OR where the MMOR was located, just as … In addition, the ECS was attached via specialized tubing to an air compressor placed just outside the … In this location, the scrubbed OR team members could assemble around the OR table to operate, just as … training on actual transfer of learning and skill development to everyday practice and to the overall culture

2149. Assessing the Safety of Electronic Health Records: What Have We Learned? | PSNet
      psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
      September 01, 2017 - The best approach to both understanding and resolving them is sociotechnical, which includes not just … 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 … When you ask people why they don't just turn off those "this could happen" alerts, there's a concern … I routinely interact with not just the leadership of ONC but all the various staff members.

2150. Module 1. Detecting Change in a Resident's Condition | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod1.html
      March 01, 2018 - If the learning culture of your audience suggests they will have problems learning together, you can … Try to get them to talk with each other, not just to you. … Try not to interrupt the role play while it is running; just let the interactions flow naturally. … For instance, the system of care may not accommodate the new practice, or the culture of care may not … Usually, culture change includes implementing and disseminating some core teaching.

2151. Implementation Coaching | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/implement/activity/coach.html
      June 01, 2023 - Transfer of knowledge on a “just-in-time” basis (training at the point of need, rather than “just in … Encourages belief in team members’ ability to succeed, by asking powerful questions to identify the source … Your organization’s culture may drive how this matching is done. … Make matches based on what fits best in your organization’s culture.

2152. Are Residency Duty Hour Rules Improving Patient Safety? | PSNet
      psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
      April 01, 2013 - This means that the local context (not just the schedules but the quality of the residents, the culture … of the program, the availability of effective information technology, and more) may be just as important … Do certain schedules, or other matters of culture, information technology, and leadership, lead to better … 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

2153. Daily Care Processes Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/daily-care-processes-guide.pdf
      January 01, 2017 - definition focuses on the broader set of preventable harms associated with mechanical ventilation, and not just … convince them that improving the care of mechanically ventilated patients and VAE prevention are not just … We are just beginning to develop independent redundancies in health care. … Adapt your intervention to the local culture and context. … Intervention success is dependent on organizational culture.

2154. Team Structure and Assembly (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_2-team-structure-speaker-notes.pdf
      July 01, 2023 - change • Hold teams accountable for team performance • Define the culture of the organization … Administration creates the climate and culture for a teamwork system to flourish by: • Establishing … • Defining the culture of the organization. 13                                                   … This philosophy serves to define a culture of safety; however, as examples in aviation and other high‐risk … incorrect perceptions of what they stand to lose, and even though these losses are not real, they are just

2155. 034-Ss-Action-Chart-Decisionmaking-Readiness (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/034-ss-action-chart-decisionmaking-readiness.docx
      April 01, 2025 - The order of approaching these key stakeholders will depend on the culture, standard processes, and existing … · Is preoperative decolonization just about reducing MRSA SSIs? No. … decolonization and nasal iodophor to be inferior to mupirocin in the prevention of S. aureus clinical cultures … shown to be more effective than decolonization with iodophor in reducing S. aureus and MRSA clinical cultures … and all-pathogen blood cultures in adult ICU patients, in the context of daily CHG bathing. 21 If using

2156. In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA | PSNet
      psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
      June 30, 2021 - COVID-19 is going to be just another scenario that we are going to have to look at when we do these … And it may not be just the hospital itself. … KH: With all this attention paid to sinks, surfaces, etc., now I'm just wondering has anybody been … Not just for COVID-19, there are so many applications. … Culture and Redesign. Agency for Healthcare Research and Quality; 2008.

2157. A Model of Care Delivery to Reduce Falls in a Major Cancer Center (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
      March 03, 2008 - The consensus was that this project was of such importance that a day-long training program, not just … The four objectives that drove the agenda were: (1) describing elements of a safe culture and the internal … Change Theory In large or complex institutions, implementing change to the culture can be difficult. … For purposes of this training program, change equated to a shift in the patient safety culture on the … The previous culture provided for complete privacy while the patient was using the toilet, so that even

2158. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843150/psn-pdf
      December 05, 2022 - a patient's name or pronouns because they do not want to enable something that goes against their beliefs … When it comes to healthcare though, their beliefs of normal shouldn’t interfere with someone’s ability … many people consider to be offensive because it suggests that you prescribe to a set of ideals or beliefs … , rather than this is just who you are.8 In these cases, healthcare is still very fallible. … We just want to be seen as humans, so that we can get our blood pressure managed on a regular basis.

2159. Difficult Encounters: A CMO and CNO Respond | PSNet
      psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
      March 01, 2018 - 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.

2160. Improving Sickle Cell Transitions, Focus Group Moderator Guide: IT Developers (pdf file)
      digital.ahrq.gov/sites/default/files/docs/survey/improving-sickle-cell-transitions-focus-group-moderator-guide-%20it-developers.pdf
      June 16, 2021 - In addition, differences between the health care culture in pediatrics and that of adult medicine can … The participant check-in sheet you just completed includes your agreement to participate in this session …  Feel free to respond to each other about these topics, not just answer my questions. … o Should the tool be developed just for mobile deployment or should it be available via web browser