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2581. Presentation: Implementing Your SSI Prevention Bundle
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_ssibundle.pptx
      December 01, 2017 - In the Compendium, it’s not just about the right antibiotic, the right timing, and the right choice, … Program for Surgery – Implementation SAY: The driving force behind the TRiP methodology is the core belief … Task Tools and technology Administrative support Performance monitoring and feedback Perioperative culture … Perioperative culture How does the perioperative culture affect adherence? … inexpensive yet effective ways to show staff what their leaders value and, ultimately, improve safety culture

2582. In Conversation with...Eric Coleman, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
      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 … I would argue that a good hospital discharge transition is just as important as a thorough admission

2583. Final Progress Report: Transitional Care Medication Safety and Reducing Medical Liability: Closing the Chasm (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/corbett-report.pdf
      January 01, 2024 - medication risk management efforts focus on preventing errors by improving systems and creating safety cultures … Results The research team for this study is just beginning to disseminate the findings.

2584. Transfusion "Slip" | PSNet
      psnet.ahrq.gov/web-mm/transfusion-slip
      June 14, 2011 - importance of careful design, but the cautious monitoring of the effects of change as well.( 14 ) Just … May 1, 2013 Staff attitudes about event reporting and patient safety culture in hospital

2585. Module 1: Preventing Pressure Injuries in Hospitals—Understanding Why Change Is Needed | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides1.html
      October 01, 2017 - evidence-based, and effective risk assessments that call for: Critical thinking and clinical judgment—not just … Create an organizational culture that focuses on safety; they are constantly aware of the possibility

2586. Preventing Pressure Injuries in Hospitals
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
      June 16, 2017 - evidence-based, and effective risk assessments that call for: Critical thinking and clinical judgment—not just … Create an organizational culture that focuses on safety; they are constantly aware of the possibility

2587. Building Your SSI Prevention Bundle: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/build-ssi-bundle-slides.html
      December 01, 2017 - Positive wound culture. Pain, redness, swelling. Diagnosis by surgeon. … Temperature (°C) at or just prior to time of incision.

2588. Research on Person-Centered Care
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/ncepcr-webinar-person-centered-care.pptx
      June 27, 2024 - literature Possible to shift focus away from individual behaviors to the purposeful use of method Aim 2 Custom … [Next slide] 46 Setting and Participants 47 Just a little bit about our patient population. … which you can see in the red box, patients were led through a standard exercise to select or craft a custom … And honestly, for some patients, it just comes down to, 'This is the only solution'." … "We just ran our reports to get those [NCCP] patients.

2589. Disposition of Comments for CER 172 Clostridium Difficile Diagnosis Prevention Treatment (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/c-difficile-update_disposition-comments.pdf
      March 29, 2016 - Studies that looked at microbiologic end points such as environmental cultures, etc., seem to be excluded … While such surrogate markers may be unreliable since data are meager relating environmental culture … We have added environmental swabbing and culture to the exclusion criteria for KQ2. … Since we were primarily evaluating test analytics we opted to use toxigenic culture and/or CCNA as … Perhaps this is just an area for future research. Thank you for the comment.

2590. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
      June 01, 2023 - Respondents with limited education or from cultures that discourage challenging professional authority … We just changed doctors. We no longer trust white doctors. … shortfalls, it would be essential to include elicitation questions as part of population-based surveys, not just

2591. Strategy 1: Working with Patients & Families as Advisors (Tool 9) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_9_AdvisorTrain_508.pdf
      March 06, 2013 - This includes people of all cultures and backgrounds. … hospital staff ask about and respect each patient’s and family’s values, preferences, goals, and cultural … backgrounds o Clinicians and hospital staff communicate clearly and share complete, unbiased, and … should work together as partners to create health care systems that are safe, compassionate, and just

2592. Table 1 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/cancer-end-of-life-indicators-symposium_research.pdf
      April 01, 2010 - Quality indicators for pain should not just focus on the level of pain, but also on the extent to which … In particular, this domain should also include caring for the family’s needs specifically, not just … The domain of spirituality includes the broad concepts of transcendence, relationships, values and beliefs … link pain indicators to improved patient outcomes • Emphasize the importance of pain relief, not just

2593. Situation Monitoring: Severe Hypertension (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring-speaker-notes.pdf
      July 01, 2023 - Huddles may require attendance from more than just the bedside nurse and attending. … Smith, your labs just returned and are notable for an elevated protein/creatinine ratio and elevated … • How do we prepare now so that we are ready to handle the next event in the way we have just discussed … Debrief after events to support patients, families, and staff Debrief regularly to establish a culture … Regular debrief sessions after such events help to establish and sustain a culture of continuous learning

2594. The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Karsh.pdf
      April 08, 2004 - error causation; human error; tools to assess safety and risk; systems design principles; safety culture … have included system redesign, error reporting systems, information technology, and improved safety culture … In addition, just like physicians, their work in health care has a direct impact on patient safety, … theories, and methods • Medical error causation • Safety tools to assess safety and risk • Culture

2595. Disposition of Comments_Comparative Effectiveness Review 255: Transitions of Care From Pediatric to Adult Services for Children With Special Healthcare Needs (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/transitions-care-pediatric-to-adult-services-disposition-comments.pdf
      May 31, 2022 - Could you just say "adolescents and young adults with a chronic physical or mental illness or physical … It says this in one location, but just to be consistent. … This may just be me. But a more detailed description could be useful. … Just for space, could combine these Thank you for the suggestion. … I was looking for very concrete recommendations – not just generalities.

2596. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
      January 01, 2024 - Just over 10% (exactly 10.2%) of reports were associated with known clinical harm to the patient. … suggest that perceived clinician indifference to a bad outcome led to patients’ loss of trust and a belief … The powerful effect of a safety culture, and the lack of understanding of high-performance systems, … and qualitative approaches to determine the useful level of detail based on empirical data, not just … a culture of safety in primary care.

2597. III. Hotline Implementation and Refinement | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/hotline/implement3.html
      May 01, 2016 - organizations’ policies and training materials related to patient safety to confirm that they upheld “just … culture” principles, emphasized opportunities for learning rather than blaming individuals, and recognized

2598. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
      July 08, 2022 - July 28, 2021 Just culture: the foundation of staff safety in the perioperative … to the Hospital July 8, 2022 WebM&M Cases Culture

2599. Strategy 1: Working with Patients & Families as Advisors (Implementation Handbook) (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Best_Practices_Hosp_Leaders_508.docx
      March 13, 2013 - This means telling patients’ stories, not just sharing statistics, when discussing successes and failures … clinicians and staff.(12) By sharing quality and safety data about the organization, leaders help create a culture … and support clinicians and hospital staff in patient and family engagement initiatives Creating a culture

2600. Final Evaluation Report -- State and Regional Demonstration in Health Information Technology: Indiana (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/state-regional-demonstration-hit-in-evaluation-report.pdf
      July 01, 2015 - Over time, quality improvement changes the culture as well as the processes so that quality improvement … comprehensive program gives us a practice-wide view of care needed for all of our patients, rather than just … For example, glycemic control (at the 9 percent level) was just 62 percent for Medicaid patients but … Over time, quality improvement changes the culture as well as the processes so that quality improvement … For example, glycemic control (at the 9 percent level) was just 62 percent for Medicaid patients but