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2261. In Conversation With... Anna Legreid Dopp, Pharm. D | PSNet
      psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
      June 29, 2020 - Just linking back to what I said previously, it’s all thanks to hearing from those members that are on … I credit the culture shift over the last 20 years to make sure that patient safety remains front and … Has that changed at all or are we just doing it differently? … We’re really pleased that we are able to open up all of these resources, not just for our members but … On that website, there is a page dedicated just for patients related to COVID-19.

2262. In Conversation with...Bradley T. Rosen, MD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
      March 01, 2008 - Over time, this was not just a service provided to teaching physicians, but private physicians who also … The outpatients have really just evolved as a bonus. … lines if a line is in place and there is a concern about a low-grade fever, or one out of four blood cultures … This is just my opinion, but I think if you drop down below 50% of your time doing procedures, you're … in, or the vessels are just too tiny or thrombosed that they need assistance with.

2263. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33814/psn-pdf
      September 01, 2016 - Let me just first say that you are making an observation of how medical care is being practiced today … However, the level of physician participation and leadership in telehealth encourages me, just as we … But it just can't work that way. … diastolic numbers into the physician's office so they can be tracking you instantaneously—it would just

2264. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49501/psn-pdf
      February 03, 2006 - The outgoing ED physician had just completed the shift and signed the patient out to the oncoming colleague … dependent outcomes invariably rely on many individual processes and interactions; the transition phase is just … Culture and high reliability organizations: the case of the nuclear submarine. J Manage.

2265. 050-Dec-Implementation-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/050-dec-implementation-notes.docx
      October 01, 2024 - : Percentage of patients on the unit with any positive MRSA clinical culture over the past year Knowing … MRSA cultures than iodophor. … Just like soap, avoid getting CHG into the eyes or ear canals. … Additionally, some patients might not realize that the bath is not just for their comfort, but for their … Slide 57 Key Takeaways SAY: We’ve just reviewed the components of the decolonization process and

2266. 3. Results | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
      January 01, 2024 - , Workflow, and Work System Issues Culture: Behavioral Norms Work System Work System: Process … Burden The burden of diagnostic errors exists beyond just health outcomes. … the detection of breakdowns in the diagnostic process. 65 Conceptual models have been developed not just … Culture: Behavioral Norms Behavioral norms in the workplace may affect diagnostic safety. … System-related aspects of diagnosis (e.g., human factors, safety culture). 243 3.9.2.

2267. Creation of a Medical Procedure Service to Improve Patient Safety | PSNet
      psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
      March 01, 2008 - The outpatients have really just evolved as a bonus. … lines if a line is in place and there is a concern about a low-grade fever, or one out of four blood cultures … This is just my opinion, but I think if you drop down below 50% of your time doing procedures, you're … But there are patients who are wildly coagulopathic that the team just doesn't want to stick a needle … in, or the vessels are just too tiny or thrombosed that they need assistance with.

2268. Snac-Final-Report-Mar2023 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/snac-final-report-mar2023.pdf
      January 01, 2025 - Action Plan to Advance Patient Safety (National Steering Committee for Patient Safety, 2020)—(1) Culture … issues of patient and workplace safety; and (2) inclusive of all settings across the care continuum—not just … harm, inspires continuous improvement in the delivery of care across the continuum, and promotes a culture … through assessing and addressing the four foundational areas outlined in the National Action Plan (culture … ***We stand for a healthcare delivery system that is free from preventable harm and promotes a culture

2269. How Do Providers Recover From Errors? | PSNet
      psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
      May 22, 2024 - The resident then realized that the effusion was on the contralateral side, not the left side she had just … conferences at many institutions.( 10,14,20,21 ) These conferences historically have been extensions of the culture … A culture shift will be necessary to create a productive process for the provider sharing the medical … New culture for coping: turning to peer support after medical errors. American Medical News.

2270. Hyperglycemia and Switching to Subcutaneous Insulin | PSNet
      psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
      May 19, 2021 - 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 … assess 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

2271. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49552/psn-pdf
      January 01, 2008 - resident then realized that the effusion was on the contralateral side, not the left side she had just … conferences at many institutions.(10,14,20,21) These conferences historically have been extensions of the culture … A culture shift will be necessary to create a productive process for the provider sharing the medical … New culture for coping: turning to peer support after medical errors. American Medical News.

2272. Critical Access Hospital Partnership Health Information Technology Implementation | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/critical-access-hospital-partnership-health-information-technology
      January 01, 2023 - health care settings, the lessons learned from addressing technological and cultural challenges can be just

2273. Six Tips for Making a Quality Report Appealing and Easy To Skim | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/resources/design/general-tips/index.html
      October 01, 2019 - Use images to reinforce main content or messages, not just to decorate the report.

2274. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.docx
      March 01, 2017 - except for fever or new-onset hypotension due to a noninfectious cause; and (4) the resident has a urine culture … indwelling urinary catheter, should the frontline staff member put on a gown at the beginning of the bath or just … A urine specimen for culture should be obtained prior to initiating antimicrobial therapy for presumed … The urine culture should be obtained from the freshly placed catheter prior to the initiation of antimicrobial … If use of the catheter can be discontinued, a culture of a voided midstream urine specimen should be

2275. Appendix F. CAUTI Prevention in Long-Term Care: Frequently Asked Questions | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.html
      March 01, 2017 - except for fever or new-onset hypotension due to a noninfectious cause; and (4) the resident has a urine culture … indwelling urinary catheter, should the frontline staff member put on a gown at the beginning of the bath or just … A urine specimen for culture should be obtained prior to initiating antimicrobial therapy for presumed … The urine culture should be obtained from the freshly placed catheter prior to the initiation of antimicrobial … If use of the catheter can be discontinued, a culture of a voided midstream urine specimen should be

2276. Automated Adverse Drug Event Detection and Intervention - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs014882-ferranti-final-report-2008.pdf
      January 01, 2008 - N/A 0.0% 0.0% 170 IV to PO Switch - Ranitidine Intervention only N/A 0.0% 0.0% 156 Positive micro culture … Therefore, we completed a pilot surveillance project of "just in time" alerts for anticoagulants. … The leadership and safety culture differences in academic versus community based hospitals observed … Additional work will also continue to define and deploy “just in time” surveillance system which solely … Implementation of Anticoagulant-Focused “Just-in-Time” Alerts in an Academic Medical Center.

2277. The Four Es of Early Mobility: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/4es-early-mobility-facguide.html
      February 01, 2017 - You cannot just decide in the morning during rounds to mobilize a mechanically ventilated patient. … Ask the question, "How will we implement early mobility at our hospital, change the culture, and provide … The execute step will help to improve the culture of safety in your unit.

2278. Accessible Health Information Technology (IT) for Populations with Limited Literacy: A Guide for Developers and Purchasers of Health IT
      digital.ahrq.gov/sites/default/files/docs/page/literacy_guide.html
      October 01, 2007 - groups, immigrants, and English -as-a-second-language speakers, it is important to pay attention to culture … It is just as important, however, that the health IT is tested repeatedly throughout the design process

2279. Accessible Health Information Technology (IT) for Populations with Limited Literacy: A Guide for Developers and Purchasers of Health IT (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/LiteracyGuide_0.pdf
      October 01, 2007 - groups, immigrants, and English-as-a-second-language speakers, it is important to pay attention to culture … It is just as important, however, that the health IT is tested repeatedly throughout the design process

2280. 4. How Do We Implement Best Practices in Our Organization? (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
      October 01, 2014 - current levels of knowledge about pressure ulcer prevention and to identify gaps in knowledge, such as beliefs … Just as we all celebrate birthdays, weddings, and other life-changing events differently, changing practice … in your hospital depends on knowing the culture of your own organization. … Each unit has its own culture; some people will be willing to try something new and others will have … Based on your hospital's culture, history, and values, begin identifying the characteristics of an approach