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461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33776/psn-pdf
     January 01, 2015 - And in collecting specimens to improve the flow instead of just focusing on cost. … huge opportunities to improve the way we manage and to engage employees in improvement, instead of just … It should be a no-blame culture. … It's going to take time to build up even just a basic level of comfort let alone building up trust to … it starts feeling like this is our new culture.

462. Engaging Staff With Stories: Transcript - Sustainability Module | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/training-tools/stories-transcript.html
     June 01, 2017 - Sharing data from the patient safety culture assessment baseline puts the plan in perspective and allows … So, sharing that alone was huge, the patient safety culture assessment baseline. … That was where I had the obstinate anesthesiologist in particular, but, you know, after I just kept visiting … It’s definitely a group effort, and it’s not just within this one facility, it’s the entire group of

463. How To Avoid the Harms of Antibiotic Overuse | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/urine-culturing/antibiotic-stewardship/part-1-slides.html
     February 01, 2019 - Why not just give her an antibiotic? It won't do any harm. Probably the urine. … Asymptomatic Bacteriuria (ASB) Versus CAUTI Bacteriuria ≠ CAUTI Bacteriuria means a positive urine culture … "Extra urine cultures lead to extra antibiotics—and that's not good for anyone." … Family says: "Let's just give him antibiotics just in case." … increase in antibiotic resistant organisms Be aware of overuse if the resident has a positive urine culture

464. Safety cultural preconditions for organizational learning in high-risk organizations. | PSNet
     psnet.ahrq.gov/issue/safety-cultural-preconditions-organizational-learning-high-risk-organizations
     June 17, 2009 - This commentary focuses on the importance of cultural redundancy as an element of a safety culture . … and safety in high-risk organizations: arguments for a sociotechnical understanding of safety culture … October 12, 2011 Multilayered approach to patient safety culture. … October 18, 2010 What is patient safety culture? A review of the literature. … July 28, 2010 Just culture: who gets to draw the line?

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33639/psn-pdf
     September 01, 2006 - , just stay out of this. … JB: Well, the biggest thing was the culture. … In other industries that are more reliable, it's that the culture is totally different. … My goal when I came here was to change the culture. … The next thing that we wanted to do was to create a culture in which people felt safe.

466. Integrating Teamwork Tools into CUSP Efforts | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/integrating-teamwork-tools-cusp-efforts-transcript.html
     December 01, 2017 - There are other important elements of this project, particularly around culture change that have to be … These are more challenging and without a culture and an environment that really promotes teamwork and … Let's just talk real briefly about what is TeamSTEPPS. … Handoffs as we just mentioned. … If you have a culture where this s encouraged, hopefully that won't happen.

467. Integrating-Teamwork-Tools-Into-Cusp-Efforts-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/integrating-teamwork-tools-into-cusp-efforts-transcript.docx
     April 07, 2015 - There are other important elements of this project, particularly around culture change that have to be … These are more challenging and without a culture and an environment that really promotes teamwork and … Let's just talk real briefly about what is TeamSTEPPS. … Handoffs as we just mentioned. … If you have a culture where this is encouraged, hopefully that won't happen.

468. In Conversation With… Mary Dixon-Woods, DPhil | PSNet
     psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
     March 01, 2017 - going right that seem very obvious to me, in the same ways we don't learn about how to avoid obesity just … For example, with the use of routine beta-blockers in surgery, where that technical intervention just … Is it just you've digitized this world, but it's the same kind of issues. … There are evolutionary reasons why it's difficult to change cultures, because they're there to keep coherence … This is just fluffy stuff." The reality is that that's usually the really hard stuff.

469. Engaging-Staff-Stories-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/engaging-staff-stories-transcript.docx
     May 01, 2017 - Sharing data from the patient safety culture assessment baseline puts the plan in perspective and allows … So, sharing that alone was huge, the patient safety culture assessment baseline. … That was where I had the obstinate anesthesiologist in particular, but, you know, after I just kept visiting … It’s definitely a group effort, and it’s not just within this one facility, it’s the entire group of

470. Key Issues in Developing a Successful Hospital Safety Program | PSNet
     psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
     July 01, 2006 - culture. … A just culture is one that supports and encourages open and honest reporting of medical errors. … It is important for officers to have a clear understanding about what it means to work in a just culture … Feedback loops are essential to move the organization toward a just culture. … Fair and Just Culture, Teamwork and Communication Training, and leadership engagement all work to make

471. An Overview of the CANDOR Process
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
     August 20, 2015 - Learn and Apply New Skills Module 8 5 Sustainability occurs when processes, outcomes, ideas, beliefs … with an organization’s commitment to make the necessary changes that promote a timely, thorough, and just … Promote just and fair culture. … staff to report CANDOR events and other adverse patient events by promoting transparency and a fair and just … culture.

472. Ed-Catheter-Insertions-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.doc
     September 10, 2013 - Real briefly, I just wanted to introduce all three of our speakers. … A few days later, he developed fever and his blood pressure dropped and blood cultures are done and the … urine cultures also; they grew the same organism, Ecoli, and he is diagnosed to have CAUTI and septicemia … What is the culture? What is your nursing culture? What is your physician culture? … Shawn Horton: Okay, I just have a quick question.

473. Two More “Es” and How To Spread (Transcript) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/how-to-spread.html
     April 01, 2013 - They also felt that there was never any failure in the belief that blood stream infections were preventable … Or “They have a different culture than we do.” … essentially people’s perceptions of the culture. … If somebody decided they wanted to do just culture, I think that they would probably be able to do that … Just trying to be more creative about just having meetings.

474. Emergency Department and Catheter Insertion | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
     December 01, 2017 - Real briefly, I just wanted to introduce all three of our speakers. … A few days later, he developed fever and his blood pressure dropped and blood cultures are done and the … urine cultures also; they grew the same organism, Ecoli, and he is diagnosed to have CAUTI and septicemia … What is the culture? What is your nursing culture? What is your physician culture? … Shawn Horton: Okay, I just have a quick question.

475. Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programmes. | PSNet
     psnet.ahrq.gov/issue/major-cultural-compatibility-complex-considerations-cross-cultural-dissemination-patient
     May 26, 2010 - December 30, 2016 Changing the "working while sick" culture. … April 22, 2016 Just-in-time training for high-risk low-volume therapies: an approach

476. The Role of Leadership in Quality Improvement Efforts (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Role_of_Leadership_In_QI-_2011_11_01.pdf
     January 01, 2011 - Like culture, leadership is another important aspect in any improvement effort, not just with patient … Can you talk a little bit about how leadership and culture are related? … That sets the culture of an organization. Carla Zema That’s great. … board every month to ensure that they’re hearing about the quality improvement work that you do is just … And so if you’re having trouble getting your issue on to the leader’s agenda, pulling together not just

477. Rethinking Patient Safety. | PSNet
     psnet.ahrq.gov/issue/rethinking-patient-safety
     April 13, 2018 - inform its discussion of key patient safety topics, including how to learn from failure and develop a culture … Copy Citation Related Resources From the Same Author(s) Just Culture: Restoring … May 16, 2018 Hospital Survey on Patient Safety Culture: 2018 User Database Report. … April 22, 2018 Strategies for Creating, Sustaining, and Improving a Culture of Safety … June 14, 2017 Leading a Culture of Safety: a Blueprint for Success.

478. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33821/psn-pdf
     December 01, 2016 - Some of the most useful insights concern three areas: how to create a just culture that is conducive … Although there is general agreement about the benefits of such a culture, many health care settings … Aviation has spent decades establishing a just culture of safety in which there are careful agreements … For example, European just culture legislation in November 2015 extended a range of legal protections … around the appropriate use of aviation safety data.(11) Such just culture principles remain patchily

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33828/psn-pdf
     March 01, 2017 - For example, with the use of routine beta-blockers in surgery, where that technical intervention just … Is it just you've digitized this world, but it's the same kind of issues. … There are evolutionary reasons why it's difficult to change cultures, because they're there to keep … MDW: Actually, just as we're talking it's occurring to me your intervention in the English health system … This is just fluffy stuff." The reality is that that's usually the really hard stuff.

480. In Conversation With… Amy C. Edmondson, PhD, AM | PSNet
     psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
     February 01, 2017 - Of course, that's just not the case. … It's just not useful anymore. … The industry culture is changing. And small changes can make a big difference. … in and uptake of TeamSTEPPS abroad, especially given the wide variation in health care and national cultures … TeamSTEPPS tools and strategies—including briefs, huddles, and debriefs—to be generalizable across cultures