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2781. Unexplained Apnea Under Anesthesia | PSNet
      psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
      December 01, 2005 - Just before the surgical incision was made, 50 mcg of Fentanyl was administered. … June 22, 2009 Organizational culture: an important context for addressing and improving

2782. Module-4-Implementation-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-4-implementation-guide.pdf
      September 01, 2021 - If you make it clear that no one will be blamed and that you just want to understand and then ask staff … Or you could just ask in a staff meeting: “How much time have you had to spend in the last month fixing … from staff or other stakeholders that data isn’t complete, accurate, or up to date you may want to just … Sometimes it’s just a number (how many patients enrolled in CR in the past 12 months). … You may not have even spoken to people that were just referred at the end of the month.

2783. Facilitator Guide: Implementing Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_ssibundle_facnotes.docx
      December 01, 2017 - In the Compendium, it’s not just about the right antibiotic, the right timing, and the right choice, … Don’t Clinicians Follow the Guidelines SAY: The driving force behind the TRiP methodology is the core belief … inexpensive yet effective ways to show staff what their leaders value and, ultimately, improve safety culture

2784. Implementing Your Surgical Site Infection Prevention Bundle: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-fac-notes.html
      October 01, 2020 - In the Compendium, it’s not just about the right antibiotic, the right timing, and the right choice, … Say: The driving force behind the TRiP methodology is the core belief that clinicians want to do the … inexpensive yet effective ways to show staff what their leaders value and, ultimately, improve safety culture

2785. 013-Ss-Cleaning-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/013-ss-cleaning-fg.docx
      April 01, 2025 - Feedback must be given in a fair and just manner; the system needs to be set up so tools, education,

2786. CancelRx: A Health IT Tool to Decrease Medication Discrepancies in the Outpatient Setting - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs025793-chui-final-report-2020.pdf
      January 01, 2020 - study found that prescribers attempted to communicate with pharmacists to discontinue a medication in just … The ISTA framework recognizes that the “actual use” of the health IT must be examined, not just the … social systems (focusing on the people in the system, the tasks they perform, and the organizational culture … Guided by the ISTA framework, unintended consequences related to more/new work, the organizational culture … Culture–technology interactions in healthcare. Decision Sciences. 2016;47(5):851-880. 20.

2787. Disposition of Comments Report for Technical Brief 15 Transition Care for Children With Special Health Needs (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/children-special-needs-transition_disposition-comments.pdf
      June 17, 2014 - However it does not provide guidance on what patient behaviors, knowledge, beliefs and attitudes etc … Peer Reviewer 13 General Role of culture and SES is not well articulated We agree that is missing … Just because people age and need to transfer doesn’t justify the need of transition programs. … So it's not so arbitrary as it sounds on line 8, page 1 and it's not just moving from a pediatrician … These are just some ideas. Thank you for your suggestions.

2788. Monitoring Ventilator-Associated Events Module 2
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/monitoring-vae-slides.pptx
      January 01, 2017 - Antifungals, limited antivirals Former Broad range of agents for healthcare-associated infections, not just … seven physicians for VAP Establish objective diagnosis by histology or quantitative bronchoscopy cultures

2789. Is Our Pharmacy Meeting Patients' Needs? A Pharmacy Health Literacy Assessment Tool User's Guide (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/pharmlit.pdf
      October 01, 2007 - health literacy—for example, determining a healthy weight for a person on a body mass index chart— just … elements: • Physical Environment • Care Process and Workforce • Paperwork and Written Communication • Culture … Finally, just some housekeeping issues: The bathrooms are located (indicate location). … This is just for our information. Please hand it back to me when you are finished. … Culture In this last set of questions, I'd like to talk about whether and how well you think the pharmacy

2790. Disposition of Comments_Systematic Review: Breastfeeding and Health Outcomes for Infants and Children (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/breastfeeding-health-outcomes-disposition-comments.pdf
      March 31, 2025 - section, it is important to add evidence of the multiple benefits of skin-to-skin care, starting just … The USBC firmly believes that breastfeeding is not just a health intervention; it is a fundamental public

2791. Personalized Clinical Decision Support to Improve Participation in Hospital at Home – Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs027248-kowalkowski-final-report-2023.pdf
      January 01, 2023 - • Facilitator: “If it comes prepopulated in the sense, or if [the EHR] can pull all the data and just … throw me a score into that app if I just put the patient’s name in—Yes, that would be really useful … • “I think it’s game-changing because…when a patient understands what to expect from a program…it's just

2792. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
      April 18, 2004 - Just 25 patients agreed to be interviewed.

2793. Future Research Needs for Childhood Obesity Prevention Programs (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/child-obesity-future_research.pdf
      March 31, 2010 - All studies should report BMI-z 11 score rather than just BMI.

2794. E-prescribing: E for error? | PSNet
      psnet.ahrq.gov/web-mm/e-prescribing-e-error
      February 03, 2021 - The clinic had just implemented electronic prescribing—the ability to electronically transmit a new prescription … October 21, 2020 An intervention to increase situational awareness and the Culture of

2795. Appendix B. In-Person Meetings | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ssi/ssiapb.html
      April 01, 2018 - Culture Type Map to Procedure Types Appendix F. Algorithms Appendix G. … Calendar Years 2007, 2008, 2009 to Makoto (# SSIs/# total surgeries)→Clarification, All Surgeries or Just

2796. Anemia and Delayed Colon Cancer Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
      July 21, 2020 - anticoagulation, he should have undergone further testing to evaluate for occult GI bleeding rather than just … Patient and visitor aggression in healthcare: a survey exploring organisational safety culture

2797. Trust and Patient-Centeredness Workgroup: Patient and Caregiver Perspectives on Generative Artificial Intelligence in Patient-Centered Clinical Decision Support (pdf file)
      cdsic.ahrq.gov/sites/default/files/2024-07/OY1_FINAL%20TPC%20Patient%20Perspectives%20Generative%20AI.pdf
      January 01, 2024 - But I don't see it as a big, scary, evil thing, unless it's just allowed to kind of run rampant.” … against excessive personalization, emphasizing the importance of avoiding "overdesign" or “If it were just … Is the doctor just going to take the summary the AI gives them as gospel? … Future studies should also explore views and beliefs from a diverse sample to identify and compare perspectives

2798. Guide to Reducing Unintended Consequences of Electronic Health Records (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/guide-to-reducing-unintended-consequences-of-electronic-health-records.pdf
      August 01, 2011 - rely more heavily on the software, and demand more sophisticated functionality and new features (e.g., custom … communication patterns and practices Example: EHRs create an "illusion of communication," (i.e., a belief … In fact, if such problems exist, implementing an EHR may just make them worse. … Custom Programming 6. Care Process Change 7. … designed to help organizations assess whether they are ready to undertake organization-wide practice or culture

2799. Improving Influenza Vaccine Uptake in Acute Care Settings - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r03hs027689-orenstein-final-report-2023.pdf
      January 01, 2023 - a default-checked influenza vaccine order automatically timed for 12 PM the day after admission, just-in-time … structure, pre-existing decision support and workflow patterns, technical infrastructure, and the culture … detailing evidence- based approaches to vaccine counseling, integrated into influenza vaccine orders for “Just

2800. Appendix F. Interventions | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/engage/appf.html
      March 01, 2017 - Patient safety culture in primary care: developing a theoretical framework for practical use Yes … No Moderate Evidence synthesis with recommendations for improving safety culture. … Is ambulatory patient safety just like hospital safety, only without the "stat"? … Building a culture of engagement for Medicare/Medicaid enrollees: health plan approaches Yes