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2161. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33608/psn-pdf
      February 01, 2024 - According to the Centers for Disease Control and Prevention (CDC), there were just over 3.6 million births … consistently safe access and equitable care, for all women regardless of systemic or provider unconscious belief … AHRQ’s Safety Program for Perinatal Care (SPPC) takes an overarching approach to improving safety culture … Just another ordinary bad birth? … Failure to rescue, communication, and safety Culture. Clin Obstet Gynecol. 2019;62(3):507-517.

2162. Pillars of a Smart, Safe Operating Room (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
      April 07, 2008 - With the MVP, just as with an actual patient, the trainee can practice communicating, ordering tests … The transparent nature of both the data collected and the subsequent analysis of the data supports a culture … Conclusion This utopian vision of the perioperative environment just described may sound unattainable … , but prototype components of just such futuristic systems currently exist in some form. … Organizational culture as a source of high reliability. Calif Manage Rev 1987; 29: 112-127. 24.

2163. Daily Goals During Interdisciplinary Rounds: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/cusp/daily-goals-rounds-slides.html
      February 01, 2017 - Matters Traits of high-performing ICUs with superior risk-adjusted survival: Have team-oriented culture … Share beliefs in providing excellent care. Communicate in an informal but direct way. … Slide 15: Using Daily Goals Do not use as "just" a checklist!

2164. Module: Daily Goals During Interdisciplinary Rounds
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/dailygoals-rounds-slides.pptx
      January 01, 2017 - Communication Matters Traits of high-performing ICUs with superior risk-adjusted survival Have team-oriented culture … Share beliefs in providing excellent care Communicate in an informal but direct way Take a collaborative … Goals ‹#› AHRQ Safety Program for Mechanically Ventilated Patients Using Daily Goals Do not use as “just

2165. Primary Care Practice Facilitation Curriculum Module 4: An Introduction to Practice Organization and Management (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-4-practice-management.pdf
      September 01, 2015 - but it is important for PFs to recognize that the enterprise of primary care is a “team sport”—not just … As mentioned earlier, primary care is a team effort—not just among clinical care team members but across … Organizational culture is the foundation for all practice activities. … Every practice has its own unique culture, and this culture will be an important factor in any work … Practices can receive reimbursements in just a few weeks or wait months or sometimes years to receive

2166. Standardized Nursing Protocol: Bed Bathing With 2% Chlorhexidine (CHG) No-Rinse Bathing Cloths and Showering With 4% CHG Liquid Soap (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/nursing-protocols/nursing-chg-bed-bathing.pdf
      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. … Devices Protocol: Bed Bathing/ 5 Showering With CHG • Remind patient that skin may feel sticky for just

2167. Improving Patient Safety in Long-Term Care Facilities: Training Modules (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcinstructor.pdf
      June 01, 2012 - Try to get them to talk with each other, not just to you. … Try to get them to talk with each other, not just to you. … Pamela had just begun telling him about Mrs. C. … o Culture. … Try to get them to talk with each other, not just to you.

2168. Making Healthcare Safer Practices: 13. Alarm Fatigue (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/alarm-fatigue-1.pdf
      March 01, 2020 - discuss two system-level patient safety practices (PSPs) that aim to address alarm fatigue: safety culture … Addressing alarm fatigue through improving safety culture involves system-wide interventions, such as … Facilitators • Securing buy-in from staff at all levels is key to achieving culture change. … Patient Safety Primer: Culture of Safety https://psnet.ahrq.gov/primers/primer/5/Culture-of-Safety. … specifically mentioned that the multidisciplinary assessment team included representatives beyond just

2169. A Frontline Management System To Sustain Improvement in Safety Practices | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/kit.html
      June 01, 2017 - level to the executive suite—was crucial to sustaining standardized practices over time and promoting a culture … Results of these preliminary tests were promising, including increases in staff satisfaction and safety culture … (1) conformance with established protocols and procedures; (2) simple issues that have an obvious “just

2170. Topics | PSNet
      psnet.ahrq.gov/topics-0
      March 03, 2025 - to this topic Informed Consent Go to this topic Culture … Safety Go to this topic Institutional Patient Safety Plan Go to this topic Just … Culture Go to this topic Learning Organization Go to this topic Red Rules

2171. What We Learned: Five Key Lessons | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/clabsi-final/clabsifinal4.html
      January 01, 2013 - from the MHA Keystone: ICU project and had well-defined interventions—the CUSP model to address safety culture … worked to adapt, coordinate, and integrate other improvement techniques and tools such as TeamSTEPPS®, Just … Culture, Lean, and Six Sigma programs with the CUSP efforts. 

2172. Final Progress Report: Infection Prevention in Emergency Care: A Systems Approach (pdf file)
      www.ahrq.gov/sites/default/files/2025-05/schuur-report.pdf
      January 01, 2025 - Emergency Departments operate within a culture that prioritizes urgent intervention over prevention, … Attendees were provided with an overview on the culture of infection prevention which focused on the … historical culture of how medicine used to be practiced and compared it to modern day perspectives: … improving system defects • “Blame and shame” o Punitive component o Diminishes peer or self reporting • “Just … culture” o Promotes questioning attitude o Resistant to complacency o Committed to excellence o Fosters

2173. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet
      psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
      December 23, 2020 - errors led to considerable soul searching and, ultimately, a major change in institutional practices and culture … We have adopted and promulgated model error disclosure practices and fair and just culture principles

2174. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33730/psn-pdf
      June 01, 2012 - That's one of the strengths if you're running an aviation reporting system and you're just trying to … It's a familiar safety story, but that was just one of those things that has now become unacceptable. … The clinicians can just get on the phone and say, "There's something very odd happening here," or, … But, ours just mushroomed and in a way tried to take on—or was pushed into—trying to do things that the … It's a little better now, but if you and I were just trying to decide how much of the patient safety

2175. Effectiveness of Early Diagnosis, Prevention, and Treatment of Clostridium difficile Infection (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/c-diff-infections_disposition-comments.pdf
      March 01, 2012 - It may be best just to eliminate the word mild. … PCR was superior to all but culture. … Peer Reviewer #4 Introduction Page 35, Line 55: “Non-standard therapy” - Why not just say non- antibiotic … All would agree that anaerobic culture for toxigenic C. … It may be too redundant to have a summary again, but just commenting.

2176. SOPS® Value and Efficiency Supplemental Items for the SOPS Hospital Survey - Spanish (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/spanish-hospital-ve-supp-item-set-2022.pdf
      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 … Development and pilot testing of survey items to assess the culture of value and efficiency in hospitals

2177. Surveys on Patient Safety Culture (SOPS) Hospital 1.0 Survey: 2021 User Database Report Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hsops1-database-report-part-I.pdf
      March 01, 2021 - Surveys on Patient Safety Culture™ and SOPS® are trademarks of AHRQ. … refers to the beliefs, values, and norms shared by staff throughout the organization that influence … Patient safety culture is the extent to which these beliefs, values, and norms support and promote patient … (Item A18) 74% 9.03% 44% 62% 69% 75% 80% 85% 100% % Disagree/Strongly Disagree It is just by chance … (Item A18) 75% 75% 0% 17% -20% 6% -6% % Disagree/Strongly Disagree It is just by chance that more

2178. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/using-checklists/checklistandauditslides.pptx
      September 03, 2014 - Just the nature of end-stage renal disease makes them immunocompromised, increasing risk. … of safety Safety culture is local and best sustained when it is accepted and maintained at the facility … Posting data can have an impact on the culture of safety.   … DO: Watch the NOTICE video “Undermining a Culture of Safety.” … DO: Select one of the defects from the “Undermining a Culture of Safety” video.

2179. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33689/psn-pdf
      October 01, 2009 - understood that health care could cause harm, this concern was too inchoate to generate real change in the culture … It cannot just be frequency: the heparin dosing error experienced by the Quaid twins has happened hundreds … Just as the physician signing the surgical site, the nurse cleaning her hands, the quality manager developing

2180. Final Progress Report: Training Doctors To Disclose Unanticipated Outcomes to Patients: Randomized Trial (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/gallagher3-report.pdf
      January 01, 2024 - Just-in-Time Disclosure Videos With technical assistance from Pacific Standard Television, we created … error disclosure videos that study physicians in the intervention arm had access to for “just-in-time … ” learning as a refresher course throughout the data collection period (Just-in-Time Error Disclosure … Cultures continues to be widespread. … Last, many new disclosure policies and recommendations recognize the critical role that just-in-time