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psnet.ahrq.gov/node/41808/psn-pdf
October 08, 2024 - specialty pharmacies to ensure medication
safety, including strategic planning, risk assessment, and Just … Culture principles. … https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
https://psnet.ahrq.gov/issue/just-culture-restoring-trust-and-accountability-your-organization-third-edition
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psnet.ahrq.gov/issue/leadership-and-vision-culture-safety
May 27, 2021 - Commentary
Leadership and vision for a culture of safety. … Citation Text:
Leadership and vision for a culture of safety. Gandhi TK. NEJM Catalyst. … Leadership has an important role in establishing a culture of safety in health care organizations. … This commentary describes key skills required of health care executives to establish and nurture the culture … Areas of focus include the importance of modeling behaviors such as transparency, adopting just culture
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psnet.ahrq.gov/node/47323/psn-pdf
September 26, 2018 - politeness, face, and feedback: exploring resident
and faculty perceptions of how institutional feedback
culture … Politeness, Face, and Feedback: Exploring Resident and
Faculty Perceptions of How Institutional Feedback Culture … The authors advocate for transitioning to a culture of
growth, which would shift their institution toward … a more just culture. … https://psnet.ahrq.gov/issue/just-culture-guide
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - Just Culture
a. … provides links to ways to engage and teach about a Just Culture, execute a Just
Culture, and Evaluate … a Just Culture. … Nursing 2015 Just Culture Toolkit
https://nursing2015.wordpress.com/blue-team/blue-team-documents/just-culture-tool-kit … -
building/
This website provides a definition of Just Culture, presentations on Just Culture, a case
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www.ahrq.gov/hai/tools/clabsi-cauti-icu/overcome/mindsets.html
April 01, 2022 - Overcoming Mindsets
It can be difficult to address your staff’s underlying attitudes and beliefs … With time, effort, and shared understanding, your team can change those attitudes and beliefs to create … a stronger safety culture. … Engaging Physicians in Preventing CLABSI and CAUTI (PDF, 286.2 KB)
Making It Work – Overcoming the "Just … ; Transcript , PDF, 304.5 KB)
Audio interview with David Thompson – How To Address Attitudes and Beliefs
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psnet.ahrq.gov/node/836969/psn-pdf
April 20, 2022 - //psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture … //psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture … https://psnet.ahrq.gov/issue/will-prosecuting-medical-errors-lead-culture-silence
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psnet.ahrq.gov/node/836932/psn-pdf
April 13, 2022 - A just culture centers on moving from blaming individuals for medical errors towards a systems-
based … psnet.ahrq.gov/issue/nurses-guilty-verdict-dosing-mistake-could-cost-lives
https://psnet.ahrq.gov/issue/just-culture-restoring-trust-and-accountability-your-organization-third-edition … psnet.ahrq.gov/issue/learning-not-blaming
https://psnet.ahrq.gov/issue/will-prosecuting-medical-errors-lead-culture-silence
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - While the patient
safety world has largely embraced the concept of a just culture for many years, this … issue/balancing-no-blame-accountability-patient-safety
https://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives … ://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives
https://psnet.ahrq.gov … The researchers worried that "rule-
based, calculus-like approaches intended to support a 'just culture … They suggested that rather than attempting to create a just
culture that balances a systems approach
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
August 01, 2022 - A Just Culture supports disclosure and learning from errors and encourages viewing every event as an … This element supports the creation of just culture. … Improved culture of safety as a result of open, fair, and just management of individual and system issues … More information on Just Culture can be found in the Apply CUSP module of the AHRQ CUSP Toolkit. … to a systems approach to Event Investigation and Analysis supports a Just Culture.
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psnet.ahrq.gov/node/837000/psn-pdf
May 06, 2022 - May 6, 2022
Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022. … lessons-learned-about-human-fallibility-system-design-and-justice-aftermath-fatal-medication
https://psnet.ahrq.gov/issue/just-culture-restoring-trust-and-accountability-your-organization-third-edition … https://psnet.ahrq.gov/issue/will-prosecuting-medical-errors-lead-culture-silence
https://psnet.ahrq.gov
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psnet.ahrq.gov/issue/failure-report-poor-care-breach-moral-and-professional-expectation
March 05, 2025 - Culture, hierarchy, and lack of opportunity can hinder reporting of concerns and mistakes. … February 22, 2017
View More
Related Resources
'Just culture': improving … May 25, 2016
Perspective: a culture of respect—part 1 and part 2. … October 23, 2013
Culture, language, and patient safety: making the link. … June 29, 2011
Telling cultures: 'cultural' issues for staff reporting concerns about
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www.ahrq.gov/patient-safety/reports/liability/prologue.html
August 01, 2017 - Transparency between and among medical colleagues and a supportive just culture 1 are also central aspects … Introduction to the Just Culture. What is just culture? Outcome Engenuity Web site. … Available at https://www.outcome-eng.com/david-marx-introduces-just-culture/ . … See for example the Survey on Patient Safety Culture Database. … Available at
https://www.ahrq.gov/topics/topic-survey-on-patient-safety-culture-database.html .
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www.ahrq.gov/sops/news/previous-announcements.html
March 01, 2025 - Updated AHRQ Surveys on Patient Safety Culture Action Planning Tool AHRQ Surveys on Patient Safety Culture … Hospitals can administer the items at the end of the SOPS Hospital Survey 2.0, just before the background … Medical offices can administer the items at the end of the SOPS Medical Office Survey, just before the … Why Choose the AHRQ Surveys on Patient Safety Culture? … Shifting to a “Just Culture” framework to assess Response to Error.
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psnet.ahrq.gov/node/38935/psn-pdf
March 01, 2017 - this sentinel event alert, the Joint Commission calls for senior health care leaders to establish a
culture … of safety within their organizations, use just culture principles to establish transparent and fair … Please review The essential role of leadership in developing a
safety culture for updated recommendations … https://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives
https://psnet.ahrq.gov … https://psnet.ahrq.gov/issue/essential-role-leadership-developing-safety-culture
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psnet.ahrq.gov/issue/criminalization-mistakes-nursing
June 13, 2011 - March 1, 2023
Just culture: it's more than policy. … June 5, 2019
Using good catches to promote a just culture and perioperative patient safety … November 14, 2018
Improving patient safety by practicing in a just culture. … October 12, 2011
Balancing just culture with regulatory standards.
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psnet.ahrq.gov/issue/i-think-we-should-just-listen-and-get-out-qualitative-exploration-views-and-experiences
June 22, 2022 - Study
'I think we should just listen and get out': a qualitative exploration of views … ‘I think we should just listen and get out’: a qualitative exploration of views and experiences of Patient … While senior leaders espoused key principles such as an open, blame-free culture and frontline staff … These findings spotlight the challenge of implementing interventions intended to bolster safety culture … ‘I think we should just listen and get out’: a qualitative exploration of views and experiences of Patient
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/module-3-slides.pptx
March 01, 2017 - 2017
1
Objectives
Cite staff empowerment concepts
Discuss how staff empowerment contributes to a culture … Leader support and teams
Communication and information sharing
Positive reinforcement
Confidence
Just … | 25
PLAY VIDEO
Video 3.5: Just Culture and Open Communication - https://youtu.be/WdN-WdWKduU
Video … 3.5: Just Culture and Open Communication
25
Barriers to Staff Empowerment10
Lack of senior leader support … Just Culture, Healthcare Services Overview.
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-slides.html
March 01, 2017 - Just Culture. … Culture 8,9
Mission, values, and expectations. … Just Culture, Healthcare Services Overview . Outcome Engineering; 2012.
9. CUSP Toolkit . … Slide 25: A Just Culture
Image: Indicating a video on the slide
PLAY VIDEO
Video 3.5: Just Culture … Just Culture, Healthcare Services Overview . Outcome Engineering; 2012.
CUSP Toolkit .
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel_facnotes.docx
December 01, 2017 - Adaptive work addresses the attitudes, beliefs, and values of clinicians that drive behaviors, norms, … This ensures we address the local values, attitudes, and beliefs that drive our actions. … Just finding the time to meet can be difficult. … Notice that “right” is in quotation marks, because a just or “right” culture sends the signal that safety … Alternatively, in cultures where the “right” thing to do is to get people in and out of beds as fast
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/overview-fac-notes.html
December 01, 2017 - Adaptive work addresses the attitudes, beliefs, and values of clinicians that drive behaviors, norms, … This ensures we address the local values, attitudes, and beliefs that drive our actions. … Just finding the time to meet can be difficult. … Notice that “right” is in quotation marks, because a just or “right” culture sends the signal that safety … Alternatively, in cultures where the “right” thing to do is to get people in and out of beds as fast