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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
April 22, 2004 - These strategies should be based on the
hierarchy of hazard control, which states that the best hazard … To help
facilitate the development of effective control strategies, a hazard-control matrix
should … A hazard-control matrix, which is based on the variance
control table,35 has 10 headings in the top … hazard-control ideas that the team develops. … Each redesign idea or hazard-control idea should subsequently be
subjected to a full system analysis
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www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-specialized-populations-icu-slides.html
December 01, 2017 - Slide 15
Changing Patient Safety Culture
Senior Leaders
Team Leaders
Staff … on Patient Safety
Infection rates
Process measures
Organizational and team culture
Slide … Slide 49
Why do ICU patients feel ‘special’? … Slide 67
On the CUSP: Stop CAUTI
A Journey to Prevent CAUTI & Improve Patient Safety in the ICU … on NSCU
Well received by staff and patients
Direct in-servicing provided to near 200 employees house-wide
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psnet.ahrq.gov/issue/patient-safety-perceptions-survey-iowa-physicians-pharmacists-and-nurses
February 01, 2012 - Study
Patient safety perceptions: a survey of Iowa physicians, pharmacists, and nurses … Patient safety perceptions: a survey of Iowa physicians, pharmacists, and nurses. … The investigators surveyed health care providers to determine their perceptions on patient safety in … Patient safety perceptions: a survey of Iowa physicians, pharmacists, and nurses. … July 23, 2010
Clear liquids may place patients at risk.
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psnet.ahrq.gov/issue/teamwork-clinical-leadership-skills-and-environmental-factors-influence-missed-nursing-care
August 04, 2010 - August 10, 2022
Risk factors for clinically relevant deviations in patients' medication … lists reported by patients in personal health records: a prospective cohort study in a hospital setting … problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses: a questionnaire … survey. … May 12, 2021
Patient safety culture improves during an in situ simulation intervention
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www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
January 01, 2024 - Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture … Structured Abstract
Purpose: Transparency is the cornerstone of patient safety culture. … , 5U18HS016658-02, "Using Team Simulation To Improve Error Disclosure to Patients and Safety Culture. … Simulation To Improve Error Disclosure to Patients and Safety Culture."
6
preferences for disclosure … and Safety Culture."
11
the team.
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psnet.ahrq.gov/issue/overtreatment-united-states
November 21, 2017 - Overuse of medical care can lead to patient harm. … In this survey study, physicians were queried about the overuse of health care as well as contributing … care can harm patients. … August 11, 2021
Association of safety culture with surgical site infection outcomes. … September 29, 2017
Development of a high-value care culture survey: a modified Delphi
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psnet.ahrq.gov/issue/principles-conservative-prescribing
April 22, 2017 - Strategies to prevent medication errors are an ongoing focus in patient safety. … prescribing, maintain heightened awareness about side effects, exercise skepticism about new drugs, work with patients … wrong-patient order errors: a randomized clinical trial. … February 28, 2024
Exploring the impact of safety culture on incident reporting: lessons … learned from machine learning analysis of NHS England staff survey and incident data.
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www.ahrq.gov/patient-safety/resources/learning-lab/index.html
August 01, 2025 - presentation: a survey of academic and community practice . … Understand and improve workspace design and safety culture to influence anesthesia medication selection … A Patient Diagnostic Questionnaire (PDQ) that aligns with the “Patient Experience” Safer Dx process … data analyses using EHRs, patient safety event reports, and patient experience surveys. … Using patient experience surveys to identify potential diagnostic safety breakdowns: A mixed methods
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module5/facilitator-notes.docx
March 01, 2017 - Facilitator Notes
SAY:
The Resident and Family Engagement module focuses on the roles and responsibilities … The core concepts of person-centered care as defined by the Institute for Patient- and Family-Centered … These surveys provide useful information that can be used to improve performance in resident- and family-centered … be a valuable team member on safety and quality committees. … just focusing on what happened.
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psnet.ahrq.gov/node/37045/psn-pdf
September 30, 2011 - Understanding and attitudes towards patient safety
concepts in obstetrics. … Understanding and attitudes towards patient safety concepts in obstetrics. … https://psnet.ahrq.gov/issue/understanding-and-attitudes-towards-patient-safety-concepts-obstetrics … This survey of staff at Egyptian maternal health centers found limited understanding of patient safety … https://psnet.ahrq.gov/issue/understanding-and-attitudes-towards-patient-safety-concepts-obstetrics
https
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psnet.ahrq.gov/issue/simulation-based-education-ensure-provider-competency-within-healthcare-system
May 02, 2018 - May 2, 2018
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … July 22, 2020
Hospital ward adaptation during the COVID-19 pandemic: a national survey … Evaluating ambulatory practice safety: the PROMISES Project administrators and practice staff surveys … December 10, 2024
Implementation of a mock root cause analysis to provide simulated patient … July 10, 2019
Five topics health care simulation can address to improve patient safety
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psnet.ahrq.gov/issue/impact-state-nurse-practitioner-regulations-potentially-inappropriate-medication-prescribing
March 24, 2021 - October 19, 2022
Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) … Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey … 2020
Physician task load and the risk of burnout among US physicians in a national survey … December 2, 2020
Impact of patient safety culture on missed nursing care and adverse … patient events.
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www.ahrq.gov/hai/cusp/toolkit/content-calls/framework.html
April 01, 2013 - cultural of safety survey. … reducing the blood stream infection rate, improve safety culture in well over 100 intensive care units … Many hospitals across the country are using AHRQ’s Hospital Survey of Patient Safety Culture. … the screensavers on the patient units. … If you can click on the survey link, that would be great.
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psnet.ahrq.gov/issue/raising-and-responding-frontline-concerns-healthcare
November 13, 2019 - Citation
Related Resources From the Same Author(s)
Whistleblowing over patient … April 8, 2019
Hospital board oversight of quality and patient safety: a narrative review … April 21, 2015
Characterising the nature of primary care patient safety incident reports … November 14, 2012
Do hospital boards matter for better, safer, patient care? … 2017
Assessing organisational culture for quality and safety improvement: a national survey
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psnet.ahrq.gov/node/41325/psn-pdf
October 06, 2016 - This survey of seven
National Health Service hospitals found poor task reliability across several clinical … in up to 37% of cases at one hospital, and at another,
clinical information was missing for 27% of patients … culture-safety
https://psnet.ahrq.gov/issue/systematic-review-psychological-literature-interruption-and-its-patient-safety-implications
-
psnet.ahrq.gov/issue/review-article-improving-hospital-clinical-handover-between-paramedics-and-emergency
February 28, 2024 - of medication errors during rapid medical response intervention for deteriorating patients in wards? … April 5, 2017
Comparison of a focused family cancer history questionnaire to family history … Safety Culture Survey. … April 22, 2015
Safe Handover: Safe Patients. … April 19, 2011
Clinical handover of patients arriving by ambulance to the emergency department
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psnet.ahrq.gov/issue/characteristics-healthcare-organisations-struggling-improve-quality-results-systematic-review
August 14, 2019 - April 13, 2011
The influence of organizational context on quality improvement and patient … July 3, 2014
Evaluation of the association between Hospital Survey on Patient Safety … Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives. … June 7, 2018
The effect of facility characteristics on patient safety, patient experience … November 8, 2017
The weekend effect in hospitalized patients: a meta-analysis.
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psnet.ahrq.gov/issue/posttraumatic-growth-and-second-victim-distress-resulting-medical-mishaps-among-physicians
January 12, 2022 - December 7, 2022
Correlation between the number of patient-reported adverse events, adverse … drug events, and quality of life in older patients: an observational study. … victim experiences of nurses in obstetrics and gynaecology: a Second Victim Experience and Support Tool Survey … Safety Culture in Healthcare
March 27, 2024
Nurse leader attitudes and beliefs … March 6, 2024
Interventions to support nurses as second victims of patient safety incidents
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psnet.ahrq.gov/issue/impact-nighttime-rapid-response-team-activation-outcomes-hospitalized-patients-acute
April 06, 2022 - Impact of nighttime Rapid Response Team activation on outcomes of hospitalized patients with acute deterioration … Impact of nighttime Rapid Response Team activation on outcomes of hospitalized patients with acute deterioration … November 21, 2016
Organizational and safety culture in Canadian intensive care units: … January 4, 2012
A survey of nurses' beliefs about the medical emergency team system in … of patient, nurse and organisational characteristics.
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psnet.ahrq.gov/node/47949/psn-pdf
July 10, 2019 - of coworker reports about unprofessional
behavior by surgeons with surgical complications in their
patients … surgical-complications
Physicians who behave unprofessionally toward other health care workers compromise both safety … culture
and patient health. … Although many have reported anecdotally that disrespectful
surgeon behavior has led to patient harm, … disruptive-and-unprofessional-behavior
https://psnet.ahrq.gov/primer/culture-safety
https://psnet.ahrq.gov/issue/survey-impact-disruptive-behaviors-and-communication-defects-patient-safety