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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - It is not just an event that happens and goes on a shelf. … culture, that culture of being able to speak up, that non-punitive culture where we are focused on improvement … How are we looking at human error versus reckless behavior (i.e., just culture)? … It's the same thing if we do not have just culture. … culture.
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psnet.ahrq.gov/node/45558/psn-pdf
May 10, 2017 - Topics discussed include just culture, disclosure, and bias. … psnet.ahrq.gov/issue/prevention-better-cure-learning-adverse-events-healthcare
https://psnet.ahrq.gov/issue/just-culture-restoring-trust-and-accountability-your-organization-third-edition
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psnet.ahrq.gov/node/47242/psn-pdf
January 01, 2021 - it-matters-what-i-think-not-what-you-say-scientific-evidence-medical-error-
disclosure
Effective error disclosure fosters a just … culture. … it-matters-what-i-think-not-what-you-say-scientific-evidence-medical-error-disclosure
https://psnet.ahrq.gov/primer/disclosure-errors
https://psnet.ahrq.gov/issue/just-culture-guide
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
September 10, 2015 - A Just Culture supports disclosure and learning from errors and encourages viewing every event as an … This element supports the creation of just culture. … Improved culture of safety as a result of open, fair, and just management of individual and system issues … More information on Just Culture can be found in the Apply CUSP module of the AHRQ CUSP Toolkit.
12 … to a systems approach to Event Investigation and Analysis supports a Just Culture.
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psnet.ahrq.gov/issue/leadership-committed-safety
December 23, 2016 - this sentinel event alert , the Joint Commission calls for senior health care leaders to establish a culture … of safety within their organizations, use just culture principles to establish transparent and fair … Please review The essential role of leadership in developing a safety culture for updated recommendations … July 19, 2016
A just culture after Mid Staffordshire.
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www.ahrq.gov/hai/cauti-tools/archived-webinars/engaging-nurse-physician-patient-transcript.html
December 01, 2017 - Second is the physician culture can also be a barrier. … Secondly to reframe values and beliefs, third was to segment the engagement plan. … The second element is about reframing values and beliefs. … Of course this requires a change in beliefs and attitudes. Next slide. … Have a belief in what you're doing.
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psnet.ahrq.gov/node/33615/psn-pdf
June 01, 2005 - simultaneously studying clinical research, health policy, and management] was to combine
those two cultures—quality … By exposing that, we revealed the
dissonance between our pride and our belief that we are a great institution … RW: In terms of big buckets—informatics, culture change, hiring more nurses, standard procedures—how … PP: Unequivocally, they should start with culture change. … It simply
says, measure your culture (we use J.
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psnet.ahrq.gov/node/867229/psn-pdf
January 01, 2025 - improving-approach-defining-classifying-reporting-and-monitoring-adverse-events-seriously-ill
https://psnet.ahrq.gov/issue/rooting-error-review-process-just-culture-lessons-learned … https://psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review
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www.ahrq.gov/hai/quality/tools/cauti-ltc/improve.html
March 01, 2017 - Improve Safety Culture
Long-Term-Care Safety Toolkit Modules
Comprises six modules (available … They support learning and implementation efforts to improve safety culture and practices in long term … AHRQ Nursing Home Survey on Patient Safety Culture
A survey available for nursing homes that helps … facilities assess staff perceptions of resident safety culture and track changes over time. … designed to assist you in developing skills and strategies to improve all aspects of resident safety, not just
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/advance-organizational-safety-strategies-slides.pdf
June 18, 2024 - behavior
training and
application
Safe
tables
PFAC
committees
Safety
huddles
Causal
analysis
Just … System
Focus
Just Culture -
consistent
understanding and
application
Financial Stability
PSO All … , Equitable, Patient-centered
NAP Assessment 2022 2024
Projection
Patient and Family
Engagement
Just … All rights reserved. 41
Quality and Safety Goals
October 2023
• Launched quality belief and new, aligned … All rights reserved. 43
OUR SHARED QUALITY BELIEF
Quality connects us.
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psnet.ahrq.gov/issue/doctors-are-more-dangerous-gun-owners-rejoinder-error-counting
June 24, 2020 - systems do not account for the "higher order" organizational characteristics that constitute the safety culture … October 11, 2017
A just culture after Mid Staffordshire. … December 9, 2014
Just culture: who gets to draw the line? … February 10, 2021
Intolerance of error and culture of blame drive medical excess. … December 15, 2014
The effect of the fit between organizational culture and structure
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/bestpractices-web-sopssurveys-transcript.pdf
June 12, 2019 - to measure
patient safety culture in a variety of facilities. … We
just expect that they'll just be increasing in their use. … Let's just see. I think, yes. … Let me
just double check. Okay. There's another question that we just got in. … The AHRQ SOPS survey or the AHRQ Surveys
on Patient Safety Culture is a safety culture survey.
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Psychologically safe cultures focus more on learning and how system failures lead to safety events rather … The concept of just culture seeks to balance this systems-based
approach to safety events with appropriate … One pre-
https://psnet.ahrq.gov/issue/just-culture-restoring-trust-and-accountability-your-organization-third-edition … Another integrative review on Just Culture showed that leaders
can demonstrate full commitment to Just … integrative-systematic-review-employee-silence-and-voice-healthcare-what-are-we-really
https://psnet.ahrq.gov/issue/requirements-implementing-just-culture-within-healthcare-organisations-integrative-review
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www.ahrq.gov/hai/cusp/toolkit/content-calls/framework.html
April 01, 2013 - must do based on the evidence to get the best outcome, and teamwork or the behaviors and attitudes and beliefs … that are part of the culture on our units. … There are a number of tools out there that are part of the Just Culture work, there are tools out there … We've developed a culture within our hospital -- and what Chris said or maybe she didn't, maybe I just … remember this from our training -- but culture is how you do things here, and we’ve changed our culture
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psnet.ahrq.gov/node/867676/psn-pdf
February 26, 2025 - A just culture promotes shared accountability and emphasizes that safety events are usually a product … facts with healthcare staff should be done with objectivity and compassion guided by
principles of just … for all employees and establishing clarity around
roles, expectations, and accountability promotes a just … culture. … modules/notes7.html
https://psnet.ahrq.gov/issue/reframing-morbidity-and-mortality-conference-impact-just-culture
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psnet.ahrq.gov/node/866405/psn-pdf
July 31, 2024 - The
authors also recommend fostering a “just culture” that advocates for system accountability. … implement-strategies-prevent-persistent-medication-errors-and-hazards
https://psnet.ahrq.gov/issue/barriers-and-enhancers-trust-just-culture-hospital-settings-systematic-review
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www.ahrq.gov/hai/cusp/modules/learn/sl-cusp.html
December 01, 2012 - Culture, and others to provide complete tools to support units in improving culture. … Apply CUSP
Introduce Just Culture principles. … Learn how Just Culture principles can augment CUSP.
Review key steps of the CUSP Toolkit . … A Just Culture system 6
Holds itself accountable.
Holds staff members accountable. … Just Culture. Plano, TX: Outcome Engineering; 2011.
Pronovost P, Goeschel C, Colantuoni E, et al.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
October 01, 2024 - Slide 12
So… What Is a Safety Culture?
SAY:
So, what is a safety culture? … It refers to the values, beliefs, and norms shared by healthcare practitioners and other personnel throughout … Patient safety culture can be measured by determining the values, beliefs, norms, and behaviors related … These are just some of the system factors at play. … A team of just physicians or just nurses won’t lead to the change efforts you’ll need.
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - it called “Just Culture.” … and a non-punitive culture. … What do you think is driving that increased awareness around culture of safety and non-punitive culture … I think as a profession we're just growing. … on individual error to a Just Culture where the system is the primary focus.
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www.ahrq.gov/hai/cusp/modules/learn/fac-cusp.html
December 01, 2012 - Just Culture, which is described in more detail later in this presentation.. … Learn how Just Culture principles can augment CUSP.
Review key steps of the CUSP Toolkit. … A Just Culture learning environment allows the review of both system design and the employee's choice … Shared responsibility is the norm in a Just Culture, and a commitment to eliminating the possibility … of error is widespread within a Just Culture