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2361. Dying in the Hospital With Advanced Dementia | PSNet
      psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
      November 01, 2016 - , and another study of 178 EMTs noted that POLST forms were often hard to locate when needed.( 15 ) Just … family had thought their doctor had been informed of their mother's death and assumed that the PCP was "just … Medicare coverage for advance care planning: just the first step. … March 31, 2022 WebM&M Cases Culture Clash No More

2362. Unseen Perils of Urinary Catheters | PSNet
      psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
      January 31, 2024 - Just prior to insertion of the catheter by a registered nurse (RN), the patient voided but the amount … Since the patient had just voided, the RN assumed the patient's bladder was empty. … focused competency-based approach to review the microbiology of CAUTI, urinalysis collection, and urine culture … As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily

2363. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49548/psn-pdf
      October 01, 2007 - Clues to the development of thyroid storm (beyond just thyrotoxicosis) could include tachycardia, atrial … When both infection and thyrotoxicosis are present, routine cultures and early initiation of broad-spectrum

2364. The Sometimes Antibiotics” Diagnoses: Sinusitis – Facilitator Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/sinusitis-guide.docx
      September 01, 2022 - discharge are not accurate predictors of a bacterial etiology in patients who do not meet the criteria just … Cultures or swabs of nasal discharge are not indicated in acute sinusitis, and the majority of patients

2365. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet
      psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
      January 23, 2017 - Workplace culture and human resource availability are common barriers to best practices To understand … Numerous barriers to reporting exist including fear of consequences, a culture of blame, perception … errors in a user-friendly and non-punitive manner are needed, as are clear reporting guidelines and cultures … The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors … October 30, 2024 WebM&M Cases Premature Closure: Was It Just

2366. Medication Handling and Compounding Errors in the Operating Room. | PSNet
      psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
      May 16, 2022 - medication dispensing machine should be used, an example of confirmation bias (evidence that confirms a belief … studied to address this concern. 13-15 The usage of D5W as a solvent for ICG has been shown to be just … Rethinking surgical safety: more than just a checklist.

2367. Implications for Practice Improvement, Research, and Policy | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults3.html
      August 01, 2024 - of geriatric syndromes, the reported diagnostic errors pertaining to geriatric syndromes are likely just … In addition, healthcare systems need to develop a nonpunitive culture that encourages active surveillance

2368. Institute for the Design of Environments Aligned for Patient Safety (IDEA4PS) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/resources/learning-lab/design-environments-long-desc.html
      April 01, 2021 - Guidance for custom alarm design: you don’t have to “crank it up to 11” . … A roundtable discussion: improving the "alarm problem" will require much more than just reducing the … Assessing the relationship between patient safety culture and EHR strategy . … Guidance for custom alarm design: you don’t have to “crank it up to 11” .

2369. Inadvertent Use of More Potent Acid Leads to Burn | PSNet
      psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
      November 01, 2023 - The physical exam revealed a raised lesion on the perineum, midline, just outside of the introitus. … November 12, 2008 WebM&M Cases Culture Clash No More:

2370. Primary Care Practice Facilitation Curriculum Module 30: Building Teams in Primary Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-30-teams.pdf
      September 01, 2015 - Just because a practice implements care teams does not mean that the team members work together well … Regardless of the level of buy-in, most care teams—just like members of a sports team—need training, … “Share the care” culture The practice and care team have transitioned from the traditional “lone physician … This involves reallocating responsibilities, not just tasks, and meaningful participation. … It also means the patient panel is seen not just as the clinician’s panel but the entire team’s.

2371. April 2022 CDS Connect Work Group Summary (pdf file)
      cds.ahrq.gov/sites/default/files/workgroups/143366/CDS_Connect_WG_April_2022_Summary.pdf
      January 01, 2022 - must recognize and establish onboarding—especially for patient partners—as an integral part of the culture … lessons from organizations excelling at patient partnering; and unearthing examples of how to transform “just

2372. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49667/psn-pdf
      October 01, 2012 - to be helpful, the instinct of all clinicians has to change from one of "this is unusual, but I'll just … Subsequently, the environmental culture needs to support and encourage clinicians to report medication

2373. Presentation: Auditing Your Briefings and Debriefings
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing.pptx
      December 01, 2017 - Just as you can audit clinical processes, you can audit briefing and debriefing processes. … defects Improve teamwork and communication tools Prework: Measure frontline perceptions of safety culture … A structured process provides a concrete way to improve your safety culture. 3 Why Briefings and Debriefings … We have a lot of work to do on just the basics.

2374. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60173/psn-pdf
      March 30, 2020 - The new cross-cutting topics, such as Safety Culture, Teamwork and Communication, etc. also help to … Just putting sepsis early detection systems in your EHR doesn’t necessarily save lives. … This is something that we are just starting to get our arms around, and we should spend more time on

2375. An Interactive Preventive Care Record (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/PreventiveCareHandbook_062912comp.pdf
      June 01, 2012 - Other practices may be able to just change how they use their current system. … ● “It’s just so easy to use and there are no complications.” … —Practice Nurse ● “It is just part of our everyday spiel, you know, when we’re talking to patients. … Developing a culture conducive to change. 3. Establishing a guiding coalition. 4. … longitudinal prevention plans, supporting self management, and ensuring incorporation of patient values and beliefs

2376. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73387/psn-pdf
      March 17, 2021 - modifications are necessary moving forward to continue to improve the safety of healthcare facilities, not just … Culture and Redesign. Agency for Healthcare Research and Quality; 2008.

2377. Presentation: Program Overview
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/assess-resident-RTI-slides.pptx
      June 01, 2021 - Send a urinalysis and a urine culture, and obtain a chest x ray. 4. … Case 2: Jonas, 5 Days Later Five days later Jonas says he feels better… but he still has a cough that just

2378. Final Progress Report: Systems Approach for Improving Region-Wide Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
      January 01, 2024 - A regional survey to evaluate the patient safety culture at each participating hospital was administered … addressing patient safety as well as how influential the Initiative was in each hospital’s patient safety culture … essential, serving as the common foundation to continuously improve work processes, change industry culture … Patient safety must be assessed using multiple metrics that capture not just a few outcomes and that

2379. Strategy 1: Working with Patients & Families as Advisors (Implementation Handbook) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Implement_Hndbook_508_v2.pdf
      January 28, 2011 - Helpful Links Just culture refers to a culture of shared accountability that encourages full disclosure … For more information about just culture, see the Agency for Healthcare Research and Quality’s CUSP … Toolkit “Apply” module, which introduces the concept of just culture. … Frame discussions of safety issues in a way that embraces just culture and the view that errors represent … Patient and family knowledge, values, beliefs, and cultural backgrounds are incorporated into the planning

2380. Shortcuts to Acetaminophen-induced Liver Failure | PSNet
      psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
      July 01, 2017 - Although limited data exist, the prevailing culture of medicine is toward nonintervention during pregnancy … and interventions in pregnancy is laudable, medical or surgical risks need to be balanced against not just … simulation training, morbidity and mortality reviews, critical thinking training, and an organizational culture