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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-ASC_Webcast_2021-Famolaro.pdf
January 01, 2021 - Safety 89%
Communication Openness 87%
25
Average % Positive Response
Teamwork 87%
Response to Mistakes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/microbiologic-specimens-slides.pptx
June 01, 2021 - Avoided the mistakes that were made in the respiratory collection process?
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ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
February 01, 2017 - Skip to main content
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ce.effectivehealthcare.ahrq.gov/innovations/perspectives/new-guide-charts-course-navigating-challenges-innovation-adoption.html
February 01, 2021 - leadership, should increase the benefits realized from the adoption of innovations and help avoid costly mistakes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2022-hsops2-database-report.pdf
January 01, 2022 - Learning—Continuous
Improvement
Work processes are regularly reviewed, changes are made
to keep mistakes … Reporting Patient Safety Events Mistakes of the following types are reported: (1) mistakes
caught and … corrected before reaching the patient and (2)
mistakes that could have harmed the patient but did not … Response to Error Staff are treated fairly when they make mistakes and there
is a focus on learning … from mistakes and supporting staff
involved in errors.
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ce.effectivehealthcare.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6p-service-recovery.html
April 01, 2022 - Axiom 4: Customers react more strongly to "fairness mistakes" than "honest mistakes."
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
June 01, 2021 - Slide 5
Swiss Cheese Model
SAY:
Let’s return to our “Swiss cheese model” to help visualize where mistakes … Sharing and understanding our previous mistakes helps everyone improve!
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ce.effectivehealthcare.ahrq.gov/cahps/surveys-guidance/hospital/about/child_hp_survey.html
February 01, 2024 - Involving teens in their care (composite measure)
Attention to Safety and Comfort
Preventing mistakes
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ce.effectivehealthcare.ahrq.gov/hai/cusp/toolkit/content-calls/phys-engagement/slides.html
June 01, 2013 - focus
Preventable harm is not acceptable
Tell your own Josie story
Competent
Learn from mistakes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/4es-early-mobility-facguide.docx
January 01, 2017 - Learn from your mistakes. Standardize care and create independent checks. … Employ a systematic process to learn from your mistakes.
The last E is evaluate.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
May 01, 2017 - These conditions are the mistakes that occur without human error. … Sensemaking is a way for a L&D unit to learn from and prevent mistakes.
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ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/overview.html
March 01, 2017 - Nonpunitive Response to Mistakes
Applying Safety Principles
Senior Leader Engagement
Staff
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-august2016.pptx
January 01, 2016 - Safety Culture
Slide ‹#›
Comprehensive Unit Based Safety Program (CUSP)
An intervention to learn from mistakes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
April 01, 2022 - Errors often occur because systems frequently are not designed to catch mistakes before they reach the … someone to be more careful is a far weaker intervention because humans are fallible and are bound to make mistakes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-psychological-safety.pdf
September 01, 2023 - encourages individuals “to express their ideas and concerns, to speak up with questions, and to admit
mistakes … program that uses interpersonal relationships to assess and enhance performance; this program recognizes
mistakes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-facguide.docx
January 01, 2017 - CUSP is a powerful process that teams employ to recover from mistakes, but also to learn from them and … prevent similar mistakes from happening again.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-facilitator-guide.docx
May 01, 2017 - Slide 18
SAY:
System design
Humans are fallible and occasionally make mistakes, either through inadvertent
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ce.effectivehealthcare.ahrq.gov/questions/resources/diagnosis/step3.html
November 01, 2020 - Being an active member of your health care team also helps to reduce your chances of medical mistakes
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ce.effectivehealthcare.ahrq.gov/teamstepps/events/webinars/jan-2017.html
January 01, 2017 - Fear of Making Mistakes/Errors Slide 39. Frame Errors Positively Slide 40. … Return to Contents
Slide 38
Fear of Making Mistakes/Errors
Dror I. … All errors need to be represented—slips, errors, mistakes.
Dror I.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-insertion/licensed-staff/licensed-catheter.pptx
March 01, 2017 - an indwelling urinary catheter, using aseptic technique, let’s go over some things to avoid common mistakes