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  1. 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.  
  2. Psn-Pdf (pdf file)

    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
  3. Psn-Pdf (pdf file)

    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 justculture. … 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
  4. 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.  
  5. 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.
  6. 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.
  7. Psn-Pdf (pdf file)

    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.
  8. Psn-Pdf (pdf file)

    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
  9. 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
  10. 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.
  11. 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
  12. 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.
  13. Psn-Pdf (pdf file)

    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
  14. 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
  15. Psn-Pdf (pdf file)

    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 justculture. … modules/notes7.html https://psnet.ahrq.gov/issue/reframing-morbidity-and-mortality-conference-impact-just-culture
  16. Psn-Pdf (pdf file)

    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
  17. 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.
  18. 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.
  19. 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.
  20. 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