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Perspectives on Safety > Perspective
with commentary by Alison H. Page, MS, MHA, Just Culture, October 2007
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
Meeting/Conference > Government Resource
Workshop Brief, User Liaison Program. Rockville, MD: Agency for Healthcare Research and Quality; June 2-4, 2003.
The goals of this workshop included sharing new knowledge, tools, and strategies for states to use in improving their patient safety programs and policies. The Agency for Healthcare Research and Quality's (AHRQ) User Liaison Program (ULP) developed the workshop to disseminate health services research findings for practical use through interactive sessions.
Journal Article > Study
Nonpunitive medication error reporting: 3-year findings from one hospital's primum non nocere initiative.
Potylycki MJ, Kimmel SR, Ritter M, et al. J Nurs Adm. 2006;36:370-376.
The investigators conducted a survey to inform the implementation of a nonpunitive medication error reporting policy and educational workshop. A comparison to post-initiative findings revealed that staff perception of reporting improved after the educational initiative.
Massoud MR, Kimble LE, Goldmann D, eds. Int J Qual Health Care. 2018;30(suppl 1):1-41.
Skills in studying, designing, implementing, and measuring improvement initiatives are necessary to ensure broad transfer of innovations. Articles in this special issue offer insights from an international consensus-building session that explored methods of creating actionable information from health care improvement work. In the editorial, the authors suggest that guidance is needed to help investigators to enhance the rigor and transferability of results to support systemwide learning and improvement.
Audiovisual > Audiovisual Presentation
Rockville, MD. Agency for Healthcare Research and Quality. June 2019.
Surveys are established mechanisms for organizational assessment of safety culture. This webinar provided an overview of the AHRQ Surveys on Patient Safety Culture. The presenters discussed the organizational characteristics required for successful web-based distribution of the survey and shared best practices for formatting, programming, and administering the surveys.