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2661. 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

2662. Chapter-3 - Sepsis Recognition (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/sepsis-1.pdf
      March 01, 2020 - staff about sepsis pathophysiology helps them to better understand and interpret screening parameters, just … Who Needs a Blood Culture? A prospectively derived and validated prediction rule. … 27%, resulting in approximately 1,053 fewer cultures per year. … Consecutive septic patients with positive blood culture; 526 patients. … The tradeoff for lower mortality was 10% more blood cultures obtained, and 5% more days on

2663. Use of Telehealth During the COVID-19 Era (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/telehealth-covid-19-disposition-comments.pdf
      January 03, 2023 - The AGS believes in a just society, one where we all are supported by and able to contribute to communities … Collection of respiratory specimens for cultures and blood laboratory values are also standard components

2664. Optimizing Health and Function as We Age: Roundtable Report (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/healthy-aging-roundtable.pdf
      September 08, 2022 - healthcare delivery human networks • Approaches from complexity science • Rapid-cycle evaluation • Just-in-time … systems are attempting, one Roundtable member emphasized the following: The time that I spend is just … discussed barriers to scale and spread, including funding and payment mechanisms; metrics; necessity for culture … for each program, where fidelity to those elements is essential, and what can be adapted to local cultures … I’m saying, why can’t what I just went through, why can’t that be like when I’m taking care of my older

2665. Disposition of Comments_Comparative Effectiveness Review No. 267: ADHD Diagnosis and Treatment in Children and Adolescents (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-267-adhd-disposition-comments.pdf
      March 25, 2024 - System centered language means that beliefs and practice about classism, ethnocentrism, racism affects … I recommend not comparing belief. … behaviors and try to correct the pathogenetic factors to heal the Heart and head and body Some family cultural … background is prone for aggression and impulsive decision making and that cultural sensitivity comes … The introduction strives to capture current clinical belief and practice, including beliefs and practice

2666. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848108/psn-pdf
      April 26, 2023 - Workplace culture and human resource availability are common barriers to best practices To understand … hospitalization because of a SAE. 23 Equipment and resource preparation 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

2667. 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

2668. Low Tidal Volume Ventilation Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-mvpguide.pdf
      January 01, 2017 - .............................................. 19 Execute: How Will We Implement LTVV Given Local Culture … therapists, and local hospital administrators is vital throughout the TRIP model continuum to create a culture … • Execute: How will we implement LTVV given local culture and resources? … them that improving the care of mechanically ventilated patients and including the use of LTVV is not just … Safety Program for Mechanically Ventilated Patients Execute: How Will We Implement LTVV Given Local Culture

2669. Making Healthcare Safer IV Rapid Review: Prevention in Adults of Infection With Transmission of Multidrug-Resistant Organisms (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs4-infection-prevention-mdro-rapid-research.pdf
      April 01, 2024 - difficile rooms, but room surface cultures after cleaning did not correlate with rates of C. difficile … any surveillance testing as well as serial positive cultures of infected patients) in their orthopedic … MRSA nares cultures obtained at outpatient preoperative visits were also used to determine choice of … ; fostering a culture of safety; having an innovative culture; seeing the benefits of a non-punitive … Just over half (5 of 9) of the included studies were conducted in hospitals, an additional three studies

2670. Detecting Med Errors in Rural Hospitals Using Technology - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015400-brown-final-report-2008.pdf
      January 01, 2008 - professionals at each hospital will be ask to participate in the Hospital Survey on Patient Safety Culture … We have done some analyses, but are just now beginning to interpret our findings. … Brown, C.A., Rudman, W., and Hart- Hester, S., “Blunt End/Sharp End” Perceptions of Patient Safety Culture

2671. 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.”

2672. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
      July 18, 2008 - technology support, time pressures, inadequately trained personnel, financial constraints, organizational culture … revealed multiple modes of failure on the part of both the physician and patient in sharing information, beliefs … Enhancing interdisciplinary team collaboration45 to improve primary/ambulatory care46 and promote a culture … Much that is written about huddles does not distinguish the rapid huddle, just described, from a pre-procedure … Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire - ambulatory

2673. 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

2674. Empty Handoff | PSNet
      psnet.ahrq.gov/web-mm/empty-handoff
      August 01, 2017 - Just as the success of a handoff must be considered along multiple dimensions, so should improvements … contributions built into the discussions Threat & Error Management Reliability established in safe cultures

2675. Breakage of a PICC Line | PSNet
      psnet.ahrq.gov/web-mm/breakage-picc-line
      June 21, 2023 - Cultures taken via blood and PICC reported moderate growth of Staphylococcus . … The tip of the central venous catheter (CVC) should be just above the superior vena cava/right atrium

2676. Disposition of Comments: Management of Suicidal Thoughts and Behaviors in Youth (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/suicidal-thoughts-youth-disposition-comments.pdf
      April 10, 2025 - Although commonly held, the belief that the Black Box Warning led to less prescribing and rising … The report should just clarify this nuance. We added this point to clarify this nuance. … For example, could just as easily argue that emotion regulation skills are what is contributing to … This just seems to be listed in Table 4. … With regard to widely-held beliefs concerning significant evidence for psychopharmacology and

2677. Case Example #2: The Health Center | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-2.html
      July 01, 2019 - threshold: 13% 151–200% of poverty threshold: 6% Unknown/not reported poverty threshold: 65% Cultural … backgrounds range from Scottish, Irish, and French backgrounds to Native Americans residing in Vermont … identify gaps in preventive care (e.g., immunization needs) for all THC patients systematically, not just … Building and Training “Everyone who works here contributes something that [is important]…you're not just … Information on medical treatments and results of new research are shared with all staff, not just the

2678. Appendix F to the Final Report Barriers to Meaningful Use in Medicaid: Analysis and Recommendations (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/BarrierstoMeaningfulUseAppendixF.pdf
      October 31, 2013 - We just want to hear what you have to say. … Guide.): • Awareness of peers who have had success with EHRs • Belief there is evidence that EHRs … scope of change – Costs (financial & other) – Lack of leadership – Risks – Organizational culture

2679. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
      psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
      September 27, 2023 - Imaging plays an important role in the detection of foreign material, not just identification of fractures … blunt injury involve greater tissue damage invisible to the naked eye and these wounds require not just … opposed to penetrating injuries—frequently involve tissue damage and devitalization, which is simply culture

2680. The San Diego Center for Patient Safety: Creating a Research, Education, and Community Consortium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Pratt.pdf
      March 01, 2004 - Subsequently, the vision of the SDCPS expanded from just research and education to become a central … engages academics, involves students, and in other ways contributes to the development of a safety culture … to be a need to disseminate basic concepts and provide practical advice to enhance the community’s culture … opportunity to enhance collaboration, network with front- line clinicians, and promote a community culture