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psnet.ahrq.gov/node/853065/psn-pdf
August 30, 2023 - Exploring the impact of safety culture on incident
reporting: lessons learned from machine learning … analysis of NHS England staff survey and incident data. … Exploring the impact of safety culture on incident reporting: lessons
learned from machine learning … analysis of NHS England staff survey and incident data. … https://psnet.ahrq.gov/primer/reporting-patient-safety-events
https://psnet.ahrq.gov/issue/enhancing-safety-culture-through-improved-incident-reporting-case-study-translational
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psnet.ahrq.gov/issue/measuring-and-comparing-safety-climate-intensive-care-units
January 05, 2011 - This study found an overall positive safety culture in intensive care units, based on a survey of providers … November 24, 2010
Effect of crew resource management on diabetes care and patient outcomes … safety culture. … June 16, 2011
Perceptions of safety culture vary across the intensive care units of a … June 16, 2011
Safety Climate Survey: reliability of results from a multicenter ICU survey
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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.
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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
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - Effective communication can have a profound impact on how patients and caregivers perceive their care … A survey found that patients consider poor communication to be one of the main causes underlying diagnostic … to solicit patient-reported outcomes via embedded surveys. 4 Providing patient access to the EHR has … safety culture. … safety culture.
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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.
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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
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psnet.ahrq.gov/issue/achieving-climate-patient-safety-focusing-relationships
December 19, 2017 - Achieving a climate for patient safety by focusing on relationships. … Achieving a climate for patient safety by focusing on relationships. … August 24, 2016
Strengthening leadership as a catalyst for enhanced patient safety culture … August 13, 2014
'Not another safety culture survey': using the Canadian patient safety … safety culture.
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psnet.ahrq.gov/issue/ahrq-safety-program-surgery
May 01, 2017 - June 21, 2016
AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative … November 23, 2016
AHRQ Nursing Home Survey on Patient Safety Culture: 2014 User Comparative … May 25, 2016
Patient Safety in Ambulatory Settings. … July 27, 2018
Hospital Survey on Patient Safety Culture: 2018 User Database Report. … January 11, 2017
Oversight Hearing on Recent Patient Safety Issues.
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psnet.ahrq.gov/issue/making-healthcare-safer-iii
March 27, 2019 - The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork … March 27, 2019
Hospital Survey on Patient Safety Culture: 2018 User Database Report. … April 22, 2018
Hospital Survey on Patient Safety Culture: 2014 User Comparative Database … October 5, 2022
Medical Office Survey on Patient Safety Culture: 2018 User Database Report … August 16, 2023
Final Report on Prioritization of Patient Safety Practices for a New
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psnet.ahrq.gov/issue/comparing-safety-climate-between-two-populations-hospitals-united-states
June 16, 2011 - January 3, 2017
The relationship between patient safety culture and patient outcomes: … September 4, 2016
Assessing patient safety culture in hospitals across countries. … May 29, 2013
The role of patient safety culture in the causation of unintended events … April 5, 2010
AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses … November 25, 2009
Measuring patient safety culture: an assessment of the clustering of
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psnet.ahrq.gov/issue/fidelity-and-impact-patient-safety-huddles-teamwork-and-safety-culture-evaluation-huddle
August 25, 2021 - Study
Fidelity and the impact of patient safety huddles on teamwork and safety culture … Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the … Based on direct observations and a survey of teamwork and safety climate, researchers concluded that … patient safety huddles across three National Health Service (NHS) trusts improved teamwork and safety … Fidelity and the impact of patient safety huddles on teamwork and safety culture: an evaluation of the
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psnet.ahrq.gov/issue/assessing-patient-safety-practices-and-outcomes-us-health-care-system
May 21, 2014 - safety, explore hospitals' experience with the AHRQ patient safety culture survey , and highlight trends … September 29, 2017
Hospital Survey on Patient Safety Culture: 2016 User Comparative Database … May 11, 2016
Hospital Survey on Patient Safety Culture: 2014 User Comparative Database … April 23, 2014
A Promise to Learn—a Commitment to Act: Improving the Safety of Patients … November 20, 2013
Hospital Survey on Patient Safety Culture: 2009 Comparative Database
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - safety culture survey.( 17 ) Almost one in seven staff members (175/1,160) reported they had experienced … Let's say a nurse on the evening shift harms a patient by administering the wrong medication. … However, in a health care system that focuses on addressing both patient incident investigations and … J Patient Saf. 2007;3:107-119. [Available at]
17. Surveys on Patient Safety Culture. … December 21, 2016
Patient safety culture and the second victim phenomenon: connecting
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psnet.ahrq.gov/issue/patient-feedback-safety-improvement-primary-care-results-feasibility-study
December 02, 2020 - December 23, 2020
Effects of interorganisational information technology networks on patient … December 9, 2020
Dimensions of safety culture: a systematic review of quantitative, qualitative … and mixed methods for assessing safety culture in hospitals. … an online national survey. … January 29, 2020
Validation of the Primary Care Patient Measure of Safety (PC PMOS) questionnaire
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psnet.ahrq.gov/issue/relationship-between-patient-safety-culture-and-intentions-nursing-staff-report-near-miss
September 15, 2021 - Study
The relationship between patient safety culture and the intentions of the nursing … The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss … The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss … and adverse events during COVID-19: a cross-sectional online survey among nurses. … March 24, 2021
The enabling, enacting, and elaborating factors of safety culture associated
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psnet.ahrq.gov/issue/high-cost-low-morale-clinical-laboratory-how-workplace-environment-impacts-patient-safety
March 06, 2005 - November 4, 2012
Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative … June 24, 2020
Medical Office Survey on Patient Safety Culture: 2016 User Comparative … June 8, 2016
Hospital Survey on Patient Safety Culture: 2008 Comparative Database Report … November 30, 2016
Hospital Survey on Patient Safety Culture: 2009 Comparative Database … analysis on improving patient safety.
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psnet.ahrq.gov/issue/confidential-physician-feedback-reports-designing-optimal-impact-performance
May 11, 2016 - Patient Safety Culture: 2016 User Comparative Database Report. … July 27, 2018
Medical Office Survey on Patient Safety Culture: 2016 User Comparative … November 1, 2016
Hospital Survey on Patient Safety Culture: 2008 Comparative Database … November 30, 2016
Hospital Survey on Patient Safety Culture: 2010 User Comparative Database … by Engaging Patients and Families.
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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.”