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Showing results for "mistakes".

1. Final Progress Report: Creating Learning Cultures Around Mistakes for Residents (pdf file)
   www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
   January 01, 2024 - Learning Cultures Around Mistakes for Residents Timothy J. … Medical mistakes are a central issue in US healthcare. … In the MICU case, although a higher percentage of mistakes occurred in isolation, 19 of the 21 mistakes … Another reason could be the nature of the mistakes themselves (i.e., more mistakes of omission that … Do House Officers Learn From Their Mistakes.

2. SOPS Community Pharmacy Survey Items and Composites (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/pharmsops-composites.pdf
   June 02, 2025 - 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.

3. Community Pharmacy Survey on Patient Safety (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-survey-english.pdf
   June 02, 2025 - Staff in this pharmacy discuss mistakes ..................... 1 2 3 4 5 9 9. … Staff are treated fairly when they make mistakes ..... 1 2 3 4 5 9 2. … This pharmacy is good at preventing mistakes ......... 1 2 3 4 5 9 7. … Staff feel like their mistakes are held against them .. 1 2 3 4 5 9 9. … are the following types of mistakes documented (in writing OR tracked electronically)?

4. Digestive Health Clinic, LLC: Slide Presentation (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/brownslides.pdf
   June 02, 2025 - 89% 81% Teamwork 86% 81% 40 40 Survey Results Staff Training 78% 79% Response to Mistakes …  Communication Openness  Staffing, Work Pressure and Pace  Staff Training  Response to Mistakes … • 78% positive for DHC vs 82% for pilot ASCs Staff are treated fairly when they make mistakes. … 81% 89% Learning, rather than blame, is emphasized when mistakes are made. 78% 70% Staff … : Continued treating mistakes as learning opportunities 49 49 Going Forward • Continue to collaborate

5. Using the AHRQ Pharmacy Survey on Patient Safety Culture (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/sorraslides.pdf
   January 01, 2014 - Communication about mistakes 8. Response to mistakes 9. Staff training and skills 10. … Documenting mistakes Patient safety “grade” (Excellent to Poor) Underlined dimensions were later … Communication about mistakes Communication about presciptions across shifts % Positive Response … that reach the patient and could cause harm but do not Mistakes that reach the patient but have no … potential to harm Mistakes that could have harmed the patient but were corrected BEFORE the medication

6. Community Pharmacy Survey on Patient Safety (doc file)
   www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-survey-english.docx
   June 02, 2025 - Staff in this pharmacy discuss mistakes |_|1 |_|2 |_|3 |_|4 |_|5 |_|9 9. … Staff are treated fairly when they make mistakes |_|1 |_|2 |_|3 |_|4 |_|5 |_|9 2. … This pharmacy is good at preventing mistakes |_|1 |_|2 |_|3 |_|4 |_|5 |_|9 7. … Staff feel like their mistakes are held against them |_|1 |_|2 |_|3 |_|4 |_|5 |_|9 9. … D: Documenting Mistakes In this pharmacy, how often are the following types of mistakes documented

7. Implementing Safety Cultures in Medicine: What We Learned by Watching Physicians (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Hoff.pdf
   January 01, 2003 - Watching medical work to understand medical mistakes Comprehending failure and mistakes in any line … which were then categorized using labels from the medical mistakes literature, such as mistakes of … Two-thirds of the surgery mistakes and near misses involved mistakes of commission. … “I develop a hierarchy of mistakes in my head. … Another reason might be the nature of the mistakes themselves (i.e., more mistakes of omission that

8. Community Pharmacy Survey on Patient Safety Culture: 2015 User Comparative Database Report Part II (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/pharmacy/2015-report-part-2.pdf
   January 01, 2015 - Communication About Mistakes 92% 86% 81% 4. … (B10) 91% 88% 89% Communication About Mistakes 1. Staff in this pharmacy discuss mistakes. … (B14) 91% 82% 71% Response to Mistakes 1. Staff are treated fairly when they make mistakes. … Communication About Mistakes 87% 86% 85% 88% 4. … Communication About Mistakes 89% 83% 84% 84% 4.

9. Community Pharmacy Survey on Patient Safety Culture: 2019 User Database Report (pdf file)
   www.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.

10. 2024 Child HCAHPS Survey Database Executive Summary (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2024-child-hcahps-infographic.pdf
    January 01, 2024 - their child's care with doctors, nurses, and other providers Low Scoring Measures Preventing Mistakes … always checked their child 's Identity before giving them medicines and told them how to report mistakes … new medicines after leaving the hospital Low Scoring Items Providers Told Parents How to Report Mistakes … 33% of respondents reported providers told parent how to report mistakes Asked About Things

11. Community Pharmacy Survey on Patient Safety Culture: 2019 User Database Report Part I (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-pharmacy-sops-database-report-parti.pdf
    January 01, 2019 - Staff discuss mistakes that happen and can talk about ways to prevent mistakes. … Response to Mistakes The pharmacy examines why mistakes happen, helps staff learn from mistakes, and … Response to Mistakes Staff are treated fa irly when they make mistakes (Cl) 82 This pharmacy helps … Communication About Mistakes 1. Staff in this pharmacy discuss mistakes. … Response to Mistakes 1. Staff are treated fairly when they make mistakes.

12. Community Pharmacy Survey on Patient Safety Culture: 2019 User Database Report Part I (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-pharmacy-sops-database-report-parti-rev091721.pdf
    January 01, 2019 - Staff discuss mistakes that happen and can talk about ways to prevent mistakes. … Response to Mistakes The pharmacy examines why mistakes happen, helps staff learn from mistakes, and … Response to Mistakes Staff are treated fa irly when they make mistakes (Cl) 82 This pharmacy helps … Communication About Mistakes 1. Staff in this pharmacy discuss mistakes. … Response to Mistakes 1. Staff are treated fairly when they make mistakes.

13. Just Culture Webcast Intro (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-1-intro.pdf
    November 09, 2016 - hosp-reports.html Defining Nonpunitive Response to Error 11 The extent to which staff feel that their mistakes … and event reports are not held against them and that mistakes are not kept in their personnel file … Nonpunitive Response to Error Survey Items – Staff feel like their mistakes are held against them. … event is reported, it feels like the person is being written up, not the problem. – Staff worry that mistakes

14. Development of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Slide Presentation (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/smith2slides.pdf
    June 02, 2025 - Response to Mistakes 8. … 23 23 ASC Composite Results % Positive Response Communication Openness 85% Response to Mistakes … affiliated ASCs were more positive (86%) than Not hospital affiliated ASCs (80%) on Response to Mistakes … safety problems, learning rather than blame is emphasized, and staff are treated fairly when they make mistakes … Smaller ASCs (1 or 2 Rooms) were more positive than larger ASCs (6 Rooms or More) on Response to Mistakes

15. SOPS® Nursing Home Survey Items and Composite Measures (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-survey-items-composite-english.pdf
    September 01, 2024 - Staff are afraid to report their mistakes. (negatively worded) A15. … Staff are treated fairly when they make mistakes. A18. … Staff feel safe reporting their mistakes. … This nursing home lets the same mistakes happen again and again. (negatively worded) D4. … Nonpunitive Response to Mistakes 6. Handoffs 7.

16. Community Pharmacy Survey on Patient Safety Culture: 2015 User Comparative Database Report, Part 1 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/pharmacy/2015-report-part-1.pdf
    January 01, 2015 - Communication About Mistakes Staff discuss mistakes that happen and can talk about ways to prevent mistakes … Response to Mistakes The pharmacy examines why mistakes happen, helps staff learn from mistakes, and … Communication About Mistakes 1. Staff in this pharmacy discuss mistakes. … Response to Mistakes 1. Staff are treated fairly when they make mistakes. … Staff feel like their mistakes are held against them.

17. Section 6B (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-6-b.pdf
    June 02, 2025 - giving medications .21 .26 .02 .15 .24 .27 .18 .16 .66 Q29 Providers told parent how to report mistakes … questions about readiness to leave .68 Q46 Provider talked with teen about care after discharge .58 Mistakes … Providers checked child ID before giving medications .25 Q29 Providers told parent how to report mistakes … communication .76 .81 .52 .77 .72 .76 (8) Involving teens in care .53 .55 .44 .57 .52 .65 .51 (9) Mistakes … .58 Nurse-child communication .56 Doctor-child communication .51 Involving teens in care .39 Mistakes

18. 2025 AHRQ Surveys on Patient Safety Culture® (SOPS®) Nursing Home Survey Version 2.0 Pilot Test Results: Appendix—Results by Respondent Characteristics (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025-nursing-home-20-pilot-test-results-appendix.pdf
    January 01, 2025 - Response to Mistakes % Strongly Agree/Agree Staff feel safe reporting mistakes. … Response to Mistakes % Strongly Agree/Agree Staff feel safe reporting mistakes. … Response to Mistakes 72% 75% 61% 7. Teamwork 70% 77% 68% 8. … Response to Mistakes % Strongly Agree/Agree Staff feel safe reporting mistakes. … Response to Mistakes % Strongly Agree/Agree Staff feel safe reporting mistakes.

19. Using the AHRQ Pharmacy Survey on Patient Safety Culture (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/motzslides.pdf
    June 02, 2025 - work to do: – Processes for exchanging information across shifts – Staff in the pharmacy discuss mistakes … – We talk about ways to prevent mistakes from happening again – Mistakes have led to positive

20. 2016 AHRQ Nursing Home Survey on Patient Safety Culture Part II (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/2016/nhsurv16-pt2.pdf
    January 01, 2016 - Nonpunitive Response to Mistakes 55% 54% 54% 47% 12. … Nonpunitive Response to Mistakes 54% 54% 12. … Nonpunitive Response to Mistakes 54% 54% 12. … Nonpunitive Response to Mistakes 53% 57% 12. … Nonpunitive Response to Mistakes 56% 53% 48% 12.