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2441. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
      March 05, 2008 - A systems approach—as advocated by the IOM—is a shift from a traditional blaming culture, which seeks … traditional incident reporting system may be due to staff education, attempts to overcome the blaming culture … reports during the study year represented 0.2 percent of patient encounters and most likely represent just

2442. Poorly Advanced Directives | PSNet
      psnet.ahrq.gov/web-mm/poorly-advanced-directives
      August 01, 2018 - can increase advance directive completion.( 5 ) Best practices, such as eliciting patients' values, beliefs … Just as with DNR orders, family members generally cannot override a patient- and physician-signed POLST … End-of-Life Care Planning August 1, 2018 Preventing harm in the ICU—building a culture

2443. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49849/psn-pdf
      January 01, 2019 - in the availability of resources to recognize and treat acute medical problems; to appreciate this, just … a growth area.(22) Additional ways to improve patient safety in psychiatry would be to enhance the culture … and mortality conferences are uncommon in psychiatry.(23) Moreover, error reporting systems—and the culture … Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use

2444. Results | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/engage/results.html
      March 01, 2017 - of respect of time, privacy, confidentiality Limited understanding of information Sensitivity to culture … and behavioral factors that may influence poor health, and becoming "information seekers" rather than just … Information available through the portal should include "all the patient’s health information and NOT just … In these models, the patients engage with the full team and not just the physician.

2445. Improving Patient Safety by Engaging Patients and Families (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
      April 30, 2025 - Patient Advocacy Reporting System (PARS) promoted professional self-governance, fostered a fair and just … and knowledge needed to effectively incorporate patient and family engagement approaches into their cultures … are conceptualized as a multidimensional construct consisting of pragmatics, health knowledge and beliefs … implement an intervention process that promotes professional self-governance, fosters a fair and just … culture of safety and kindness, and reduces avoidable lawsuit risk.

2446. Teach-back: Interactive Module Slides (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/static_teach-back_module.pdf
      January 01, 2013 - (hover over icons below for examples) Info Point 1: “Just to be safe, I want to make sure we are on … Info Point 8: Foster an office culture around teach-back that helps patients and their families feel … Most clinicians state once they master teach-back, it takes just about a minute to complete. … Yes In your own words, just to be safe, what are some possible side effects of the medicine?

2447. Disposition of Comments Technical Brief 30 Assessment Tools for Palliative Care (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/palliative-care-tools-disposition.pdf
      May 04, 2017 - indicated “their initial thoughts” or just “bubbled in an answer.”” … valuable additional information you have provided and we have added this issue to the discussion on culture … p. 55 typo in heading clutre instead of culture Thank you for your comment. … Probably should state "culture" instead of "clutre" Line #3 of search strategy also begins with typo … indicated “their initial thoughts” or just “bubbled in an answer.

2448. Disposition of Comments Technical Brief 30 Assessment Tools for Palliative Care (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/palliative-care-tools-disposition.pdf
      May 04, 2017 - indicated “their initial thoughts” or just “bubbled in an answer.”” … valuable additional information you have provided and we have added this issue to the discussion on culture … p. 55 typo in heading clutre instead of culture Thank you for your comment. … Probably should state "culture" instead of "clutre" Line #3 of search strategy also begins with typo … indicated “their initial thoughts” or just “bubbled in an answer.

2449. National Healthcare Quality And Disparities Report Patient Safety Chartbook (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
      October 01, 2018 - New baselines were just established using 2015 data. … Medical Office Survey on Patient Safety Culture • The AHRQ Medical Office Survey on Patient Safety Culture …  Examine trends in patient safety culture change over time. … Hospital Survey on Patient Safety Culture • The 2018 AHRQ Hospital Survey on Patient Safety Culture … • PSOs help providers:  Assess patient safety culture.

2450. Substance Use Tools & Resources Guide | The Academy
      integrationacademy.ahrq.gov/products/substance-use-resources/environmental-scan/substance-use-tools/guide
      March 01, 2024 - collection since then, and the collection has expanded to cover substance use more broadly, rather than just

2451. 025-Assessing-Evc-Webinar-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/025-assessing-evc-webinar-notes.docx
      October 01, 2024 - improvement is effective performance assessment and constructive feedback in a non-blame, empowering culture … crucial that this is implemented in a supportive environment, so that feedback can be given in a fair and just … conducting effective performance assessments and providing constructive feedback in a non-blame, supportive culture

2452. Florida Final Report
      hcup-us.ahrq.gov/datainnovations/clinicaldata/FL4AHRQProjectFinalReportMar2010_v2.jsp
      July 01, 2016 - The hospitals extracted three quarters of laboratory and blood culture data, based on admissions from … the Chief Quality Officer at BayCare Health System, she suggested that instead of collecting data of just … thousands of laboratory records and that coding the data into HL7 would consume more resources than just … Miami Children’s Hospital blood cultures have fractured specimen types – because the epidemiologist is … in LOINC mapping, because some sites break out the venous, arterial and capillary specimens, versus just

2453. TeamSTEPPS for Improving Diagnosis Participant Workbook (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-particpant-workbook.pdf
      February 04, 2022 - Patient Stories, Blogs, Registries Patient Satisfaction Surveys, Complaints Employee Satisfaction, Culture … They are exactly the same, just a different view. … Did your perspective change once you read that the two images are the same, just presented in a different … � Lab data (culture data, respiratory viral panel, COVID testing, beta natriuretic peptide, D-dimer, … accident, a patient receives a call that says to contact an orthopedic physician; a wrist fracture was just

2454. Maternal Morbidity and Mortality (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/product/pdf/mmm-draft-protocol-amendment.pdf
      February 02, 2022 - PECOTS KQ1 KQ2 Population Pregnant persons potential entry into prenatal care Birthing persons just … birthing setting across the 1-year postpartum period Outcomes of interest will be from the time just … KQ2: Birthing persons just prior to, during, or immediately following delivery (before release from

2455. Learning from Errors in Ambulatory Pediatrics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
      February 01, 2004 - This sort of change, and development of “a culture of learning,” is an important step toward developing … It is a widely held belief that medical errors are a significant problem, yet it is difficult to estimate … Instead, it just asked practitioners to report whether the error resulted in any harm. … Training in error identification and error mechanisms, and in the systems, culture, conditions, and … Each practice must recognize how to assess its own culture and design, and conduct effective tests

2456. Final Progress Report: Enhancing the Detection and Management of Adverse Drug Events in the Nursing Home (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/handler-report.pdf
      January 01, 2024 - Safety Culture of Nursing Homes:  Opinions of Top Managers.  … Comparing the safety culture of nursing homes and hospitals. … Home Health Care: More than Just a Visiting Nurse [Invited Editorial].  … Patient Safety Culture: A Review of the Nursing Home Literature and Recommendations for Practice.  … Nursing home administrators' opinions of the resident safety culture in nursing homes. 

2457. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
      January 01, 2003 - that reduce the potential for reporting medication errors are management practices and professional cultures … they are good friends and coworkers, or because the reporting clinician recognizes that she/he is just … • Assess the patient safety culture in combination with other measures, e.g., extent of implementation … Without open and supportive organizational, professional and work group cultures—each of which encourages … Organizational culture, continuous quality improvement and medication administration error reporting

2458. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867651/psn-pdf
      February 26, 2025 - on Normal Accidents and HROs 1990s and on Swiss Cheese and Safety Management 2000s and on Safety Culture … viewed, as well as the utility of the concept of human error.1, 13-15 This questioning of long held beliefs … enables the incorrect assumption that observations in this limited subset of cases demonstrate not just … Hollnagel terms this the causality credo, which he defines as “the belief that adverse outcomes happen … and early adoption.23 Work as Done and Work as Imagined “Work-as-Done” and “Work-as-Imagined” are just

2459. Chapter 2. Electronic Searchable Catalog | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program2.html
      April 01, 2018 - Just culture— techniques for facilitating an organizational culture that promotes accountability and … Analysis 206 Quality Improvement Strategies 186 Communication Improvement 179 Culture

2460. The Role of Graduate Medical Education (GME) in Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
      February 01, 2010 - They also recommended improvements to the culture of safety through error detection, reporting, and monitoring … is now a required element for accreditation for all hospitals.( 23 ) Collaborations with Others Just … We are just now graduating our first group of general surgeons under these standards. … We need to begin to talk about those issues because it may not just be duty hours. … And we need to get at all of those issues, not just the duty hours.