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2461. 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

2462. 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

2463. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33660/psn-pdf
      December 01, 2007 - coming in for follow-up, only for them to berate me about the terrible episode of care that they had just … Then there's a series of two or three phone calls after that, just to see how things went and whether

2464. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
      psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
      September 25, 2019 - July 19, 2023 Rooting an error review process in just culture: lessons learned. … WebM&M Cases Delayed Recognition of a Positive Blood Culture

2465. 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. 

2466. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49651/psn-pdf
      May 01, 2012 - Blood cultures were positive for E. coli, and appropriate antibiotic therapy was initiated. … of intraventricular gentamycin with resolution of ventriculitis as documented by negative E. coli cultures … they do.(11) Therefore, in handoffs, senders underestimate how much information receivers need, not just

2467. Info FAQs | Agency for Healthcare Research and Quality
      www.ahrq.gov/faqs/index.html?page=3
      December 20, 2012 - Publications & Research Quality Measures SafetyNet StateSnapshots/NHDRQRnet Surveys on Patient Safety Culture … Can I modify the Surveys on Patient Safety Culture? … changing the order of items or response options, deleting one or more items, and adding supplemental or custom … supplemental items or additional items from other surveys must be added to the end of the SOPS survey, just

2468. Disposition of Comments Report for CER 134 Pharmacotherapy for Adults With Alcohol-Use Disorders in Outpatient Settings (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/alcohol-misuse-drug-therapy_disposition-comments.pdf
      May 13, 2014 - We have placed the assessment of drugs with just 1 available study to an Appendix. … Response TEP Reviewer #2 General Some concern with comparing studies done in diverse countries and cultures … an empiric question (whether the medications have varying efficacy or effectiveness for different cultures … outcome (and just the mental summary score of that secondary outcome). … But at the moment, we just don't know for sure. Thank you.

2469. Peripheral IV in Too Long | PSNet
      psnet.ahrq.gov/web-mm/peripheral-iv-too-long
      September 15, 2011 - While most cases of phlebitis are noninfectious (just inflammation of the vein), this can progress to … Blood cultures drawn at the time grew methicillin-resistant Staphylococcus aureus (MRSA), most likely … phlebitis.( 1,2 ) In a prospective study of 3165 patients, however, the majority of phlebitis cases were culture-negative

2470. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49699/psn-pdf
      February 01, 2014 - identifying, reporting, and analyzing medication errors, all organizations should actively cultivate a culture … identifying, reporting, analyzing, and reducing the risk of medication errors • Cultivation of a just … culture of safety Table 2.

2471. 030-Hand-Hygiene-Webinar-Slides-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/030-hand-hygiene-webinar-slides-notes.docx
      October 01, 2024 - products and availability, knowledge levels, opportunities for additional education, as well as the safety culture … When deciding the best way to disseminate data, consider the hospital and unit culture. … Slide 27 Engage SAY: Whether just starting out or working to revitalize an existing program, it is … improvement and promotion strategies by identifying and addressing barriers specific to the workflows and culture … safety climate or lack of accountability · Measurement, including issues like distrust in data, lack of belief

2472. Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture to Improve Equitable Maternal Healthcare Delivery and Outcomes (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/product/pdf/respectful-maternity-care-protocol.pdf
      September 16, 2022 - Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture to Improve Equitable … Project Title: Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture … From 2018 to 2019, just ahead of the COVID-19 pandemic, maternal mortality rates in the US increased … bundle framework28,29 by emphasizing teamwork and communication to improve patient safety and the culture … framework,41 including populations that may vary by geographic location or residence, race/ethnicity/culture

2473. All in the History | PSNet
      psnet.ahrq.gov/web-mm/all-history
      February 28, 2011 - The paramedics had just arrived in the ED with a critically ill patient.

2474. Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/adhd_disposition-comments.pdf
      October 01, 2011 - impairments; excellent beginning …condition is identified clinically in the context of society and culture … Heavily invested stakeholders (not just the industry but academic medicine, journals, media etc. … Amphet is in the search so it is just missing from the list of stimulants? … You could just drop the “and” phrase from the end of that sentence. … Or was it just an artifact of those having these side effects dropping out?

2475. A Partnership for Clinician EHR Use and Quality of Care - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r18hs017191-pohl-final-report-2011.pdf
      January 01, 2011 - Furthermore, the partnership model placed a particular emphasis on fostering a collaborative culture … Lab results communicated to pt. in timely manner 2 5 5 (n=2) 1 center improved Practice Management/Culture … Had high level o f responses. “… just knowing that the medications are correct, the doses … The only frustration is just the IT issues and they are getting better. … In just a few weeks you know we were all being thrown off and that was a huge concern but you know they

2476. Maternal Safety and Perinatal Mental Health | PSNet
      psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
      March 28, 2023 - Can you please tell us just a little bit about yourself and your current role? … Celebrities have spoken about it, and the culture of social media has normalized talking about mental … I experienced a perinatal mental health condition myself, and I remember thinking that I must just not

2477. Research Protocol: Clostridium difficile Infection Update (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/c-difficile-update_research-protocol.pdf
      December 23, 2014 - States use enzyme immunoassay because it is fast, inexpensive, and technically easy to perform.17 Just … Toxigenic culture and cell cytotoxicity neutralization assay are no longer clinical standard practice … • Positive environmental cultures. … difficile Infection Intermediate outcomes § Appropriate antibiotic usage § Positive environmental cultures … , toxigenic culture, and cell cytotoxicity neutralization assay, we will use toxigenic culture as the

2478. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care | PSNet
      psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
      June 01, 2003 - Since the patient with COPD just admitted appeared to be improving rapidly, and the other nurses were … The solutions are multifaceted, and all solutions begin with the nursing culture of the organization … This commentary has expressed both proactive and just-in-time approaches to making patients safe.

2479. Using-Health-It-To-Support-Qi (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/using-health-it-to-support-qi.pdf
      March 01, 2015 - Factors supporting the use of health IT for QI in primary care Having a practice culture with a … In total, [to] be more proactive about how we manage our patients instead of just being reactive.” … staff, because these kinds of outcomes are “things that…health care providers care about as opposed to just … As Richelle Koopman, M.D., M.S., from UMHS stated, “There is power to just having the data, but if you … exemplary uses and best practices to inspire and guide primary care practices seeking to create a culture

2480. Double Dosing, by the Rules | PSNet
      psnet.ahrq.gov/web-mm/double-dosing-rules
      February 03, 2010 - The policy mandating that all new medications be given within 4 hours of being ordered had just been … Dynamics: If the organization functions in a hierarchical model of patient care, move toward a culture