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2641. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
      January 01, 2024 - Burden The burden of diagnostic errors exists beyond just health outcomes. … the detection of breakdowns in the diagnostic process.65 Conceptual models have been developed not just … to how culture, behavior, and work system influence diagnostic safety were limited. … was including search materials mostly since 2013 onward, so we missed certain key items published just … Improving test result follow-up through electronic health records requires more than just an alert.

2642. Impact of Healthcare Worker Safety and Wellness: A Systematic Review (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/worker-safety-wellness-protocol.pdf
      October 26, 2024 - , limited resources, understaffing, workplace violence, role conflict, and time pressures (to name just … Patient Safety Culture: The Impact on Workplace Violence and Health Worker Burnout. … How Does Workplace Violence–Reporting Culture Affect Workplace Violence, Nurse Burnout, and Patient … Behaviors that undermine a culture of safety Available from: https://www.jointcommission.org/-/media … Relationship among safety culture, nursing care, and Standard Precautions adherence.

2643. AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety | PSNet
      psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
      August 31, 2020 - in the use of PPE and infection control principles and practices, and a supportive workplace safety culture … the use of health IT to improve safety for both patients and providers, and strengthening the safety culture … Lastly, the field is just beginning to understand the burden for patients with prolonged symptoms related … weaknesses so that all critical components of the system will be better prepared for the future, not just

2644. The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meyer_41.pdf
      March 03, 2008 - We chose just a few initial organization-wide adoption targets for our program to keep the organization … physicians were given the full financial reward ($500, $1,250, or $2,500 depending upon their wRVU tier) just … communications, (3) integrity r on 27 ut appropriate attention to our soil” (our organizational culture … Other components of that strategic planning included safety culture surveys, quality and safety leadership

2645. Final Progress Report: Improving Patient Safety: Health Systems Reporting, Analysis and Safety Improvement Research Demonstrations (pdf file)
      www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
      January 01, 2025 - The units were started at staggered times, and the pilot is just now ending, with the final few reports … survey addressing healthcare workers’ attitudes toward 1) medical errors in general, 2) the medical culture … Results Key Findings: Surveys are just beginning to be analyzed.

2646. 3. Defining Categorization Needs for Race and Ethnicity Data | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/iomracereport/reldata3.html
      May 01, 2018 - Coverage and Quality in Cancer Registries The American Indian or Alaska Native population makes up just … aggregation of data on cancer incidence, an especially important task because unique circumstances of culture … Categorizing Diverse Populations A wide range of cultures, languages, and health-related behaviors

2647. Training and Events Calendar | The Academy
      integrationacademy.ahrq.gov/news-and-events/calendar
      January 01, 2025 - will cover the importance of assessing an organization’s experience, infrastructure, capacity, and culture … What does it truly mean to be Recovery Ready, not just in principle but in practice? …

      What does it truly mean to be Recovery Ready, not just in principle but in practice? …

      Discussion topics will include:

      • The influence of job design, caregiving and community culture … informal support networks alongside formal systems of care
      • Practical tools for becoming not just

2648. Tracking Patient Outcomes | The Academy
      integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/monitor-patient-and-program-progress/tracking-patient-outcomes
      February 01, 2024 - They may just need changes to their treatment plan. … Started Understanding the Components of MAT Addressing Organizational Readiness and Culture

2649. Preventable Rash | PSNet
      psnet.ahrq.gov/web-mm/preventable-rash
      October 01, 2012 - Just as important, given a potentially transmissible disease, the case provides an opportunity to examine … system that flags a positive lab result (eg, a high titer syphilis serology, or a positive gonococcal culture

2650. Final Progress Report: Caregiver innovations to reduce harm in Neonatal Intensive Care (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/thomas-report.pdf
      January 01, 2025 - participants associated with the NICU and Parent Advisory Council (PAC) to examine perceptions, attitudes, beliefs … These initial insights were just the beginning of many stories with issues that surfaced and influenced … Use of parent-centered safety culture tool (PCSCT) assessment. … Just as new parents were being identified, the COVID-19 epidemic put a stop to all activities. … The unit culture improved as well to include verbal report of UPEs in different forums.

2651. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability | PSNet
      psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
      May 27, 2020 - Transport continued, but just prior to reaching the OR, bradycardia recurred, with accompanying loss … May 18, 2022 Effect of a multispecialty faculty handoff initiative on safety culture

2652. Too Tight Control | PSNet
      psnet.ahrq.gov/web-mm/too-tight-control
      March 20, 2013 - phagocytosis [3,4]), it is tempting to extrapolate that tight control will benefit medical, and not just … June 2, 2019 Evaluation of the culture of safety: survey of clinicians and managers in

2653. Strategy 1: Working with Patients & Families as Advisors (Implementation Handbook) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Best_Practices_Hosp_Leaders_508.pdf
      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

2654. Improving Customer Service and Access in a Surgical Practice (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/Case_Study_Specialty_Practice_Updated.pdf
      October 01, 2011 - • Gave Holiday bonuses to all specialty practice staff, not just those affiliated with the department … to query the medical center operations systems and seek out the data; the practice did not have a culture … The culture of the specialty practice and of the hospital as it relates to outpatient practices did … Managed Care 101 for general staff Front office staff who just passed the assessment examination; … and higher than the FPG average of 92. 45 STEP 6: MONITOR IMPROVEMENTS FOR SUSTAINABILITY Just

2655. Final Progress Report: SAFER: Standardizing Admissions for Elderly residents (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/coburn-report.pdf
      January 01, 2024 - inquiry method •Provide technical assistance to nursing facilities regarding AHRQ Patient Safety Culture … (%) readmissions •nfection rate •Error rate •Score on handoffs/ transitions on AHRQ Patient Safety Culture … to nursing facilities to pilot their first trial of the AHRQ Nursing Home Survey on Patient Safety Culture … a forum for sharing implementation strategies; a venue for sharing tools and forms; and pertinent, just-in-time … Many acknowledged challenges in finding the common ground among unique workplace cultures and practices

2656. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
      January 01, 2023 - Workplace culture and human resource availability are common barriers to best practices. … Improving Patient Safety: Equipment and Resource Preparation (1) • Procedural sedation requires not just … • 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

2657. Final Progress Report: Improving Patient Safety by Examining Pathology Errors (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/raab-report.pdf
      January 01, 2025 - implement and test at each institution were significantly limited by departmental and organizational cultures … All administrators articulated a belief in the value of Lean methods for achieving quality and safety … pay for performance should be introduced for the entire testing pathway (cross disciplinary) and not just … Transforming to a quality culture: The Henry Ford Production System. … Custom quality measures in healthcare: beyond Lean. 2007 World Conference on Quality and Improvement

2658. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation | PSNet
      psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
      November 25, 2020 - counts and either high or moderate bandemia, respectively, bandemia was associated with positive blood cultures … Same Author(s) WebM&M Cases Premature Closure: Was It Just

2659. Promoting Use of an Integrated Personal Health Record for Prevention - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r21hs018811-krist-final-report-2012.pdf
      January 01, 2012 - These domains and themes present the learning collaborative members’ beliefs, fears, and preparations … It’s just a different way to handle it. It’s not additional work.” … Domain: facilitators Themes Quotes Practice culture amenable to change. … [Nurse] “We just cut a huge chunk of workflow every day.” … [Nurse] “This just gets better and better with how we document.”

2660. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33745/psn-pdf
      February 01, 2013 - In just the past few months, the Commonwealth Fund reported a striking degree of international variation