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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/pharmsops-composites.pdf
June 19, 2018 - Staff in this pharmacy discuss mistakes.
B13. … Staff are treated fairly when they make mistakes.
C4. … Staff feel like their mistakes are held against them. … This pharmacy is good at preventing mistakes.
C9. … Communication About Mistakes
9. Response to Mistakes
10.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-pharmacy-sops-database-report-appendix.pdf
January 01, 2019 - Response to Mistakes
1. Staff are treated fairly when they make mistakes. … Communication About Mistakes
1. Staff in this pharmacy discuss mistakes. … Response to Mistakes
1. Staff are treated fairly when they make mistakes. … Communication About Mistakes
1. Staff in this pharmacy discuss mistakes. … Communication About Mistakes
1. Staff in this pharmacy discuss mistakes.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - Staff feel like their mistakes are held against them
(1
(2
(3
(4
(5
9. … Mistakes have led to positive changes here
(1
(2
(3
(4
(5
10. … It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … Staff worry that mistakes they make are kept in their personnel file
(1
(2
(3
(4
(5
17. … 2
(3
(4
(5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes
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talkingquality.ahrq.gov/sops/international/hospital/translators.html
October 01, 2014 - Mistakes have led to positive changes here.
A13. … It is just by chance that more serious mistakes don't happen around here. … Staff feel like their mistakes are held against them. (negatively worded)
A12. … Staff worry that mistakes they make are kept in their personnel file. … (negatively worded) ( More about this item: Staff worry that their mistakes are being documented, are
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2023-SOPS-Nursing-Home-DB-Part-II.pdf
January 01, 2023 - Nonpunitive Response to Mistakes % Strongly Agree/Agree
Staff are treated fairly when they make mistakes … Nonpunitive Response to Mistakes % Strongly Agree/Agree
Staff are treated fairly when they make mistakes … Nonpunitive Response to Mistakes % Strongly Agree/Agree
Staff are treated fairly when they make mistakes … Nonpunitive Response to Mistakes % Strongly Agree/Agree
Staff are treated fairly when they make mistakes … Nonpunitive Response to Mistakes % Strongly Agree/Agree
Staff are treated fairly when they make mistakes
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - Staff feel like their mistakes are held against them
(1
(2
(3
(4
(5
9. … Mistakes have led to positive changes here
(1
(2
(3
(4
(5
10. … It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … Staff worry that mistakes they make are kept in their personnel file
(1
(2
(3
(4
(5
17. … (5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the following mistakes
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-survey.pdf
June 06, 2018 - Such prevention
includes reducing mistakes, errors, incidents, events, or problems that lead to patient … effective team ...................... 1 2 3 4 5 9
SECTION C: Organizational Learning/Response to Mistakes … Staff are treated fairly when they make mistakes ...... 1 2 3 4 5 9
3. … Learning, rather than blame, is emphasized when
mistakes are made ................................. … in This Facility
SECTION B: Teamwork and Training
SECTION C: Organizational Learning/Response to Mistakes
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
December 22, 2017 - Staff feel like their mistakes are held against them ................................... … Mistakes have led to positive changes here .............................................. … It is just by chance that more serious mistakes don’t happen around
here ......................... … Staff worry that mistakes they make are kept in their personnel file ......... … 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the following mistakes
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talkingquality.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html
March 01, 2017 - A Just Culture is one that allows teams to learn from mistakes in a safe environment. … In failure, you are given an opportunity to learn from your mistakes and continue to improve processes … System design
Humans are not perfect and occasionally make mistakes, either through unintentional errors … All humans make mistakes, and it is important to differentiate between human error and at-risk behavior … Slide 25: A Just Culture
Say:
A system of Just Culture recognizes that people make mistakes.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
May 31, 2023 - Blaming the people who made mistakes.
e. Attending the autopsy.
11. … Leaders not make mistakes.
e. Everyone agrees with the plan. … Focus on the safety, not the error
• A debrief would be good, but not to have the nurse “explain her mistakes
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talkingquality.ahrq.gov/teamstepps/instructor/reference/learnbench.html
March 01, 2014 - Blaming the people who made mistakes.
Attending the autopsy. … Leaders not make mistakes.
Everyone will agree with the plan. … Focus on the safety, not the error
A debrief would be good, but not to have the nurse "explain her mistakes
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2023-child-hcahps-chartbook.pdf
January 01, 2023 - Low Scoring
Measures
Preventing Mistakes
and Helping You Report
Concerns
61%
of respondents reported … always checked t heir child's ident ity
before giving m edicines and told t hem
how to report mistakes … The lowest scoring measures were
Preventing Mistakes and Helping You Report Concerns (61 percent), and … (Page 4 of 4)
Attention to Safety and Comfort Measures
Composite Measure/Item Name
Preventing Mistakes … (Q29)
• Never
• Sometimes
• Usually
• Always
Mistakes in your child’s healthcare can include things
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-II.pdf
January 01, 2023 - Response to Mistakes % Strongly Agree/Agree
Staff are treated fairly when they make mistakes. … Response to Mistakes 89% 85% 85% 83% 86% 86% 87% 83% 85%
7. … Response to Mistakes % Strongly Agree/Agree
Staff are treated fairly when they make
mistakes (Item … Response to Mistakes % Strongly Agree/Agree
Staff are treated fairly when they make
mistakes. … Response to Mistakes % Strongly Agree/Agree
Staff are treated fairly when they make mistakes.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
September 01, 2019 - (A6) ---- 78%
---- Dropped 1.0
item
--------------------------------------- Mistakes have led to … (A6R)
Staff feel like their mistakes are held against them. … ------------- 65% ---- ---- New 2.0 item
--------------------------------------- Staff worry that mistakes … (A6) ---- 78%
---- ------------ Dropped 1.0 item
--------------------------------------- Mistakes … (A6R)
Staff feel like their mistakes are
held against them.
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talkingquality.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
June 01, 2023 - Ensuring that mistakes or oversights are caught quickly and easily. … provide a safety net or an error prevention or error interruption mechanism for the team, ensuring that mistakes
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
August 01, 2019 - In this unit, staff feel like their mistakes are held against them. (negatively worded)
A7.
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talkingquality.ahrq.gov/cahps/surveys-guidance/hp/about/child-survey-measures.html
June 01, 2017 - leave the hospital
Q47 Provider talked with teen about care after leaving the hospital
Preventing Mistakes … Providers checked child’s identity before giving medicines
Q30 Providers told parent how to report mistakes
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
May 01, 2023 - Communication About Mistakes 7
Composite Measure 9. Response to Mistakes 7
Composite Measure 10. … Communication About Mistakes
1. … Response to Mistakes
1. … Response to Mistakes, #2, Incident Decision Tree
Composite Measure 11. … Response to Mistakes
1.
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pilot-results-parti.pdf
September 01, 2019 - 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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talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
June 09, 2016 - In this unit, staff feel like their mistakes are held against them
1
2
3
4
5
9
7.