-
www.ahrq.gov/faqs/index.html?page=21
Healthcare Cost and Utilization Project (HCUP) Job Opportunities & Internships Medical Expenditure Panel Survey … Men's & Women's Health) Publications & Research Quality Measures SafetyNet StateSnapshots/NHDRQRnet Surveys … on Patient Safety Culture TalkingQuality TeamSTEPPS Technology Assessments U.S. … These councils involve patients, consumers, and a variety of practitioners and professionals from health … These councils involve patients, consumers, and a variety of practitioners and professionals from health
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/safe_surgery_finalreport.pdf
December 01, 2017 - using the AHRQ Hospital Survey on Patient Safety Culture (HSOPS). … Sustainability
(Months 21–24)
Readminister the Hospital Survey on
Patient Safety Culture (HSOPS … on Patient Safety Culture) Resources. … These results are compared to aggregate surgery data from AHRQ’s Hospital Survey on Patient Safety
Culture … The database serves as a resource for comparing patient safety culture survey
results to those of other
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Stalhandske_71.pdf
February 23, 2008 - We sent surveys to all VA inpatient facilities to gather data on how emergency airway
management was … In total, the survey
respondents estimated that there were 11,007 non-OR emergency intubations per year … Because the survey did not ask who performed the intubations, we do not have good data on
what proportion … Based on survey results, in 2002, over half of VA facilities used colorimetric analyzers (CO2
analyzers … EDDs, on the other
hand, may provide a false reading of esophageal intubation in obese patients or those
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
June 15, 2003 - SAFETY CULTURE
SAFETY INFRASTRUCTURE
DATA INFORMATION KNOWLEDGE LEARNING
Shared … Safety culture
A safety culture is the product of individual and group values, attitudes,
perceptions … Overall, these
mechanisms appear to have been useful for fostering a regional safety culture in
which … By attempting to build a regionwide safety culture and infrastructure, PRHI has
begun to chip away the … Safety culture assessment: a tool
for improving patient safety in healthcare
organizations.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/data-change-slides.pptx
April 01, 2022 - safety culture survey results
Staff safety assessments
Outcome and device utilization data
Process auditing … Safety Culture3,4
Purpose is to examine details of safety culture in the ICU/hospital
All staff encouraged … to complete the survey
Validated tools
Hospital Survey on Patient Safety Culture (HSOPS)
Safety Attitudes … Questionnaire (SAQ)
Safety, Communication, Organizational Reliability, Physician & Employee Burnout, … a safety culture survey again
AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI
Using
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
March 06, 2025 - culture. … on Patient Safety Culture (SOPS)
• Feedback from Patient Safety Leadership WalkRounds
Tools
• … Design
spaces for patients with behavioral health conditions that provide safety for
patients and healthcare … sought to understand architects'
perspectives on designing patient rooms to reduce fall risks. … Optimize Patient Care During Transitions
Rationale: Patients are vulnerable at the many intersections
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-facguide.docx
January 01, 2017 - Briefly, teams should first educate all staff members on the science of patient safety. … Focusing on what our patients need requires a variety of informed perspectives. … This role provides safety culture survey support for teams and gathers trends from local data. … First, set a goal to exceed 80 percent response rate on your local patient safety culture surveys. … Valid safety culture scores require participation from the majority of the frontline staff.
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/forming-cusp-team-fac-guide.html
February 01, 2017 - Briefly, teams should first educate all staff members on the science of patient safety. … Focusing on what our patients need requires a variety of informed perspectives. … This role provides safety culture survey support for teams and gathers trends from local data. … First, set a goal to exceed 80 percent response rate on your local patient safety culture surveys. … Valid safety culture scores require participation from the majority of the frontline staff.
-
www.ahrq.gov/faqs/index.html?page=16
January 01, 2014 - Centers (EPCs) Freedom of Information Act (FOIA) Funding & Grants Guidelines Health Care Information for Patients … Healthcare Cost and Utilization Project (HCUP) Job Opportunities & Internships Medical Expenditure Panel Survey … Safety Network (PSNet) Patient Safety Organizations (PSOs) Permissions Primary Care Practice-Based Research … Men's & Women's Health) Publications & Research Quality Measures SafetyNet StateSnapshots/NHDRQRnet Surveys … on Patient Safety Culture TalkingQuality TeamSTEPPS Technology Assessments U.S.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-teamwork-leadership-2025.pdf
January 01, 2025 - Safety Culture Through Teamwork and Communication:
TeamSTEPPS®, states the project’s focus was to expand … culture. … Time to patient stabilization (TTS; completion of primary survey, secondary survey)
was used as a criterion … and Safety Culture
2006–2009
$598,963
Final Report
Purpose: To determine whether team-based simulation … culture, increases patient satisfaction, and promotes patient safety.
-
www.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
January 01, 2010 - To assist
organizations
and their
units in
improving
patient safety
culture, AHRQ
developed and … released the
Hospital Survey
on Patient Safety
Culture
(www.ahrq.gov/qual/patientsafetycul
ture … It focused further on
reporting systems, risk assessment,
safety culture, clinical process
improvement … care,
and patient safety culture change,
among other developments. … Safety”
Hospital Survey
on Patient Safety
Culture
2003 2004 2005 2006 2007 2008 2009
AHRQ
-
www.ahrq.gov/faqs/index.html?page=13
Centers (EPCs) Freedom of Information Act (FOIA) Funding & Grants Guidelines Health Care Information for Patients … Healthcare Cost and Utilization Project (HCUP) Job Opportunities & Internships Medical Expenditure Panel Survey … Safety Network (PSNet) Patient Safety Organizations (PSOs) Permissions Primary Care Practice-Based Research … Men's & Women's Health) Publications & Research Quality Measures SafetyNet StateSnapshots/NHDRQRnet Surveys … on Patient Safety Culture TalkingQuality TeamSTEPPS Technology Assessments U.S.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-2-presentation.pdf
May 01, 2007 - Children’s, Neurosciences, Women’s and
Cancer Hospital
• ~850 beds
• Chapel Hill, NC
My Role
• Patient … – Chief of Staff – 2007 - 2014
– General Counsel – 2014 - present
Non-punitive Response to Error Survey … Results over Time
Survey
Administration
Period
UNC Medical
Center
Average %
Positive
Database … Staff who see other staff doing something unsafe for patient care
tell them it is unsafe.
4. … University of North Carolina Health System
UNC Medical Center
My Role
Non-punitive Response to Error Survey
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/128-what-are-4es-one-pager.docx
April 01, 2025 - The 4 Es framework identifies four important elements when implementing patient safety interventions: … technical objectives of improving practices and the adaptive objectives of establishing a culture of patient … needs to be robust.
· Consider multiple methods of monitoring—e.g., direct observation, record review, surveys … and make adjustments in real-time.
· Meet regularly to review performance, discuss issues, and decide on … Integrating CUSP and TRIP to improve patient safety. Hosp Pract (1995). 2010 Nov;38(4):114-21.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-event-reporting-revised.docx
April 01, 2022 - infection are not identified on history, on examination, or from other lab testing. … What catheter alternatives were available on inserting unit for this patient? … If documented, did the patient and/or family receive education on the urinary catheter and what they … Urine Culture Practices in the ICU; Antibiotic Stewardship; Practical ICU Tools; Using Results from the Safety … Culture Surveys. https://www.ahrq.gov/hai/cauti-tools/archived-webinars/urine-culture-practices-icu-slides.html
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast4-yount.pdf
June 02, 2025 - of the Hospital SOPS
• Goals of the item set:
– Raise awareness about impact of Health IT on
patient … Process
Review literature
and existing
surveys
Identify and
convene
Technical Expert
Panel … wrong or patients
are having to call us back…to update their med list.” … “I have not been trained at all on how to use this
program…It seems no one has the time of day
to … “I wish that the nurses would be consulted more
frequently on how to improve the EHR.”
-
www.ahrq.gov/sites/default/files/2024-07/gallagher4-report.pdf
January 01, 2024 - The third paper to be published from this survey addressed the emotional impact of
errors on physicians … This paper was
published in The Joint Commission Journal on Quality and Patient Safety (2007;33:5-14 … Respondents endorsed disclosing errors to patients’ families, and many
had done so. … In that survey, risk managers
reported substantial involvement with patient safety. … and Safety Culture.”
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/ipe-large-org-webcast-skootsky.pdf
March 01, 2021 - 3 prompts (staff, provider, improvement areas)
# Surveys (95% Adult, 5% Child –All active
PCP and … Individual
Provider
Summary
Leadership
Distribution
Clinical Managers
Distribution
29
40,000 Total Surveys … Service Recovery
All patients
receive a text-
based survey
15 minutes
after their
clinic visit ( … 1-5
rating)
Physician
Communication
Workshop
Focused on
doctor-patient
communication
for new … background
• Review of practice site CG-CAHPS Survey results
• Share clinical department survey data
-
www.ahrq.gov/hai/tools/surgery/modules/on-boarding/data-into-action-slides.html
December 01, 2017 - Culture Survey Results for Improvement
Using Safety Culture Survey Results for Improvement
Slide … Slide 4: Making HSOPS Data Meaningful
Work units that debrief around safety culture perform better … Safety culture debriefing facilitators. … Image: Picture displays page 1 and page 2 of the safety culture check up tool. … Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meurer.pdf
January 01, 2004 - and better practice-based
educational intervention tools on quality improvement efforts and patient … Framework for the influence of WMIRS patient safety reports and educational
manuals on medical injury … Structured surveys
We developed a set of surveys to be completed by Wisconsin hospital quality
improvement … Rates of medical injuries and formal survey results by study groups are
pending. … Patient safety
efforts should focus on medical injuries. JAMA
2002;287(15):1993–7.
11.