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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-West_102.pdf
March 31, 2008 - three-
quarters of errors reported by family physicians to a primary care error reporting system were
mistakes … the occurrence of medical errors.26 Until we can create a culture
that embraces learning from our mistakes … A string of
mistakes: The importance of cascade analysis in
describing, counting, and preventing medical
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ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncil2.html
April 01, 2018 - There is a new wave of consumers who have heard stories of or actually experienced errors, mistakes,
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-facguide.docx
January 01, 2017 - SAY:
CUSP is an adaptive intervention that helps teams identify and learn from mistakes, improve safety … CUSP is designed to improve safety culture and help teams learn from mistakes.
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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.pdf
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/cusp/toolkit/content-calls/two-more/slides.html
May 01, 2013 - Listen to resisters
Standardize, create independent checks and learn from mistakes
Evaluate
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ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/technical/4es-early-mobility-facguide.html
February 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/teamstepps/longtermcare/module6/ts2-0ltc_module6_support_evbase.pdf
January 01, 2013 - e.g.,
inexperienced, incapable, overburdened, about to make an error), helping others correct their
mistakes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module6/ebmutualsupp.pdf
January 01, 2013 - e.g.,
inexperienced, incapable, overburdened, about to make an error), helping others correct their
mistakes
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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-care/cathetercare-maintenance.pptx
March 01, 2017 - Cautioning team members about potentially unsafe situations
Self-correcting and helping others correct their mistakes … Cautioning team members about potentially unsafe situations
Self-correcting and helping others correct their mistakes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
January 01, 2017 - Presentation: Program Overview
Learn From Defects in Care of Mechanically Ventilated Patients
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-34-EF
January 2017
Learn From Defects ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this ses…
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
June 05, 2008 - • Collecting and analyzing data on medical errors to determine whether there are areas where
mistakes … Media mistakes in coverage of the Institute
of Medicine’s error report.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
July 01, 2023 - Often we are already aware of our
limitations, shortcomings, and mistakes. … People can
feel targeted and embarrassed when their mistakes are pointed out in public,
and they may … Recognize that we are all trying to do the best we can and making
mistakes is hard on us.
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support.pptx
July 01, 2023 - Often we are already aware of our limitations, shortcomings, and mistakes. … People can feel targeted and embarrassed when their mistakes are pointed out in public, and they may … Recognize that we are all trying to do the best we can and making mistakes is hard on us.
-
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/unlicensed-staff/scenario-instr.docx
March 01, 2017 - BLADDER SCAN – POLICY #2202 12/11/06
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
AHRQ Safety Program for Reducing CAUTI in Hospitals
Urinary Catheter Types and How To Care for Them Activity
Staff Role Play—How good are your catheter care skills?
Roleplaying can be a helpful training and educational tool. Rolep…
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ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/archived-webinars/integrating-teamwork-tools-cusp-efforts-slides.html
December 01, 2017 - Cross Monitoring:
Watching each other’s backs
Ensuring mistakes/oversights are caught
STEP checklist
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ce.effectivehealthcare.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/10-tips/index.html
June 01, 2018 - Evidence shows that acute and chronically fatigued medical residents are more likely to make mistakes
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/AHRQ-Hospital-Survey-2.0-Users-Guide-5.26.2021.pdf
January 01, 2021 - Learning—
Continuous Improvement
Work processes are regularly reviewed, changes are made to
keep mistakes … from happening again, and changes are
evaluated.
3
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.
2
Response to Error Staff are treated … fairly when they make mistakes and there is a
focus on learning from mistakes and supporting staff
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ce.effectivehealthcare.ahrq.gov/patients-consumers/care-planning/errors/20tips/20tipssp.html
August 01, 2018 - Skip to main content
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ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/cusp/forming-cusp-team-fac-guide.html
February 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/hai/tools/mvp/modules/cusp/overview-cusp-mvp-facguide.html
February 01, 2017 - Say:
CUSP is an adaptive intervention that helps teams identify and learn from mistakes, improve safety … CUSP is designed to improve safety culture and help teams learn from mistakes.