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psnet.ahrq.gov/issue/using-coworker-observations-promote-accountability-disrespectful-and-unsafe-behaviors
June 27, 2018 - View more articles from the same authors. … and lack of speaking up are hallmarks of dysfunctional safety culture , which can be resistant to change … The number of reports increased during the intervention, suggesting that team members saw a benefit to … November 16, 2022
Addressing the Loss of Trust in Safety Culture. … Addressing the paradox plaguing patient-centered care.
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psnet.ahrq.gov/issue/effect-interventions-improve-safety-culture-healthcare-workers-hospital-settings-systematic
September 06, 2023 - interventions to improve safety culture on healthcare workers in hospital settings: a systematic review of the … View more articles from the same authors. … September 6, 2023
The Irish National Adverse Events Study (INAES): the frequency and … in adverse event rates in the Irish healthcare system. … February 7, 2024
Interprofessional learning in multidisciplinary healthcare teams is
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psnet.ahrq.gov/issue/stakeholder-perceptions-and-attitudes-towards-problematic-polypharmacy-and-prescribing
July 10, 2019 - View more articles from the same authors. … 7 XML Endnote tagged PubMedId RIS
Download Citation
Related Resources From the … July 10, 2019
Medication safety incidents associated with the remote delivery of primary … November 1, 2023
Primary care teams' reported actions to improve medication safety: a … use of the PINCER intervention in primary care: a qualitative exploration using the Theoretical Framework
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psnet.ahrq.gov/issue/applying-thematic-synthesis-interpretation-and-commentary-epidemiological-studies-identifying
August 25, 2021 - View more articles from the same authors. … The analysis identified several directions for future research, including exploring ways to avoid the … Same Author(s)
The problem with 'My Five Moments for Hand Hygiene'. … duration of the Hawthorne effect on hand hygiene events. … November 11, 2020
Helping healthcare teams to debrief effectively: associations of debriefers
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psnet.ahrq.gov/issue/preparedness-covid-19-situ-simulation-enhance-infection-control-systems-intensive-care-unit
June 29, 2011 - Preparedness for COVID-19: in situ simulation to enhance infection control systems in the … Preparedness for COVID-19: in situ simulation to enhance infection control systems in the intensive care … View more articles from the same authors. … ability of healthcare teams to effectively use personal protective equipment (PPE), the use of intubation … August 18, 2010
View More
Related Resources
The calm before the
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psnet.ahrq.gov/issue/nursing-implications-early-warning-system-implemented-reduce-adverse-events-qualitative-study
October 27, 2021 - View more articles from the same authors. … Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to … a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the … to change prescriber behaviour and improve safety. … August 3, 2022
Examining the effect of quality improvement initiatives on decreasing
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psnet.ahrq.gov/issue/lessons-learned-implementing-chronic-opioid-therapy-management-system
July 13, 2022 - View more articles from the same authors. … The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing … The toolkit is available as supplemental material. … 7 XML Endnote tagged PubMedId RIS
Download Citation
Related Resources From the … June 15, 2022
Building a program of expanded peer support for the entire health care
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psnet.ahrq.gov/issue/exploring-how-ward-staff-engage-implementation-patient-safety-intervention-uk-based
December 21, 2016 - View more articles from the same authors. … Frontline staff engagement with the intervention was highly variable and the intervention was not implemented … as intended across the study sites. … Does team reflexivity impact teamwork and communication in interprofessional hospital-based healthcare teams … beneath the surface?
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - plan, however, there are cases in which decision-making capacity may change due to fluctuating mentation … the lack of multidisciplinary teams involved in a patient’s care. … For example, teams that do not include a social worker or mental health professional may not have the … and its prognosis, and the healthcare teams will have a better understanding of the values and goals … September 4, 2019
Measuring the teamwork performance of teams in crisis situations: a
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psnet.ahrq.gov/issue/healthcare-professionals-perception-safety-culture-and-operating-room-or-black-box-technology
March 02, 2022 - View more articles from the same authors. … Measuring psychological safety and local learning to enable high reliability organisational change … Improving the implementation and adherence of the surgical safety checklist: a quality improvement project … in the operating room. … October 6, 2016
Reliability of a revised NOTECHS scale for use in surgical teams.
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psnet.ahrq.gov/node/72624/psn-pdf
January 05, 2021 - internal capacity necessary to continue to drive change. … Hospital and system-level teams should review the data regularly to allow for
modification and refinement … to each hospital’s culture of
safety, organization, and readiness to change. … At the initiation of the HEN 2.0 contract, LifePoint established the NQP as the framework to not only … use of
interdisciplinary care teams, bedside shift reports, prioritizing patient engagement) and providing
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - rapid response teams? … Nurses who have actually participated in urgent response teams tell me that the outcomes for the patients … only 16% of hospital CEOs listed patient safety among their top three concerns in 2004—no significant change … response teams and the use of evidence-based strategies to prevent ventilator-associated pneumonia. … blueprint to guide culture change in the nurse practice environment.
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Safety, Radiology Quality and Safety, and the Center for Evidence-Based Imaging (CEBI) teams, identified … The focus of working group meetings is subject to change, and it may be
expanded or altered based on … input from data and information technology teams to
identify target patient populations. … For instance, duties conducted by grant staff were transitioned to operational teams. … Identify drivers of change to ensure patient safety and to minimize patient harm.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - The resident came to the floor, told the nurse she was “stupid” and confidently explained that the case … The attending then called the operating room to cancel the case. … Case: Difficult Encounters (5)
The following day, the CMO reviewed the nurse's intervention with the … today than in past
A few senior physicians have lost privileges
Safety innovations (rapid response teams … , time outs, etc.) have helped
Teamwork training has helped change culture
But more change is needed
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - , so the two teams opted to keep the gastrostomy tube for gastric venting and to place a nasojejunal … The patient’s spouse then called the surgery clinic to change the follow-up visit; he revealed that his … transhepatic PEG tube, which contributed to the change in the original management plan. … A third systems solution might be to minimize the number of teams that offer percutaneous enteral tube … risk of adverse events, care teams should implement tactics to minimize the risk of adverse events.
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - Trauma teams have benefited from review of previous cases by
identifying defects in teamwork (7), just … like professional sport teams that routinely use video to review their
past performance. … illustrating technical procedures,
video is used for dissemination of best practices, such as bedside shift change … Structured, routine post-action reviews, either by individuals or by teams, are also becoming more
prevalent … appd001
https://psnet.ahrq.gov//#ref15
https://psnet.ahrq.gov//#ref3
become available, individuals and teams
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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - Teach students that the improved communication and teamwork skills that will support cultural change … RW: A lot of discussion in the patient safety world is about how to change the culture of physicians … I have personally seen a change, just in working with the committees that I'm on. … The technology will change the role of the pharmacist, to a greater focus on drug information provision … I was in New Zealand to give a talk, and because of the time change I couldn't sleep.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - Transitions in Care
Shift change over
Two or more workers exchange mission-specific information, responsibility … Practices of high reliability teams: observations in trauma resuscitation. … stage
Clinicians content with diagnosis of urinary tract infection for explanation of mental status change … change was due to urinary tract infection. … for this patient
Post-turnover
Clinicians did not reconsider diagnosis of UTI with mental status change
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - reduced hospital admissions is the use of teams of nurse practitioners (NPs) (or physician assistants … [PAs])
and physicians in managing SNF patients.(13) Such teams often have more time dedicated to the … These fundamental
staffing principles are necessary but not sufficient to change behavior and improve … Teams of physicians and nurse practitioners (or physician assistants) can be highly effective in
managing … Early
learnings have led
to adoption of
cross-continuum
teams in other
states and regions
as well
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psnet.ahrq.gov/node/33828/psn-pdf
March 01, 2017 - RW: How does the digitization of a health care work environment change the kinds of issues that we've … Change the ability to improve care, improve safety, and improve quality? … The effect of that system change is to reimagine even what the work is. … , between teams
and teams. … change.