-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
March 23, 2008 - All but two respondents (15/17)
marked the most important cause of adverse events as mistakes made by … [N (%)] 16 (94) 1 (6) 17
Mistakes made
by nurses
Mistake made
by physicians
Mistakes made by … How many mistakes with serious consequences have you made in
the last 6 months and the last 2 years? … 1 Confidential (only used to learn how to prevent future mistakes)
2 Also released to the public … (Check
one only.)
1 Mistakes made by nurses
2 Mistakes made by physicians
3 Mistakes made by
-
www.ahrq.gov/patient-safety/resources/match/matchap12.html
August 01, 2012 - Speak Up™ Initiatives include:
Things You Can Do To Prevent Medication Mistakes —Questions to ask … at the clinic, hospital, doctor's office, or pharmacy to help prevent medication mistakes; this resource
-
www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/nursing-home/2014/nhsurv14-notes.html
November 01, 2014 - job keeping residents safe") and a negatively worded item (such as, "This nursing home lets the same mistakes … Table N1 shows an example of computing a composite score for Nonpunitive Response to Mistakes . … percent positive scores results in a composite score of .50 or 50 percent on Nonpunitive Response to Mistakes
-
www.ahrq.gov/news/newsroom/case-studies/cquips0903.html
October 01, 2014 - Taking its cue from the report, PHA sought to encourage hospital clinical staff disclosure of lapses, mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/child-hcahps-overview-survey.pdf
April 12, 2022 - Child:
How well nurses communicate with your child 70%
Attention to Safety and Comfort:
Preventing mistakes
-
www.ahrq.gov/sites/default/files/2024-12/li-report.pdf
January 01, 2024 - safety culture performance (e.g.,
management support for resident safety, nonpunitive response to mistakes … 9.836 <.000
Domain 4: training and skills 1.990 .495 11.952 <.000
Domain 5: nonpunitive response to
mistakes … low RN turnover, PSC scores for compliance with
procedures (domain 3), nonpunitive response to mistakes … hospital), our unadjusted models showed that 10-percentage-point increases in nonpunitive
response to mistakes … For nonpunitive response to mistakes and overall perceptions of resident safety, these
associations
-
www.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.
-
www.ahrq.gov/patient-safety/reports/liability/baker.html
August 01, 2017 - Research has shown that when health care professionals disclose their mistakes, payouts for claims against … include patients and families in the care team and how to communicate with patients about the risks and mistakes … Research has shown that when providers disclose their mistakes, payouts for claims against the doctor … to be effective team members, and how to communicate with patients and families about the risks and mistakes … Possible scenarios were proposed to the group to facilitate the conversation around disclosing mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-data-file-specs-052419.pdf
May 15, 2019 - = Does not apply or Don’t know
blank = Missing
SECTION C: Organizational Learning/Response to Mistakes … Staff are treated fairly
when they make
mistakes
C2 Column V
1 = Strongly disagree
2 = Disagree … Learning, rather than
blame, is emphasized
when mistakes are made
C4 Column X
1 = Strongly disagree … in This Facility
SECTION B: Teamwork and Training
SECTION C: Organizational Learning/Response to Mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport_0.pdf
March 01, 2018 - Frequency of events reported Mistakes of the following types are reported: (1) mistakes
caught and corrected … before affecting the patient, (2)
mistakes with no potential to harm the patient, and (3)
mistakes … them and that mistakes are not kept in their
personnel file.
7. … (A6)
84%
Mistakes have led to positive changes here. … Mistakes have led to positive changes
here.
64% 64% 0% 18% -41% 4% -5%
A13 3.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport.pdf
March 01, 2018 - Frequency of events reported Mistakes of the following types are reported: (1) mistakes
caught and corrected … before affecting the patient, (2)
mistakes with no potential to harm the patient, and (3)
mistakes … them and that mistakes are not kept in their
personnel file.
7. … (A6)
84%
Mistakes have led to positive changes here. … Mistakes have led to positive changes
here.
64% 64% 0% 18% -41% 4% -5%
A13 3.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2018hospitalsopsreport-rev0921.pdf
March 01, 2018 - Frequency of events reported Mistakes of the following types are reported: (1) mistakes
caught and corrected … before affecting the patient, (2)
mistakes with no potential to harm the patient, and (3)
mistakes … them and that mistakes are not kept in their
personnel file.
7. … (A6)
84%
Mistakes have led to positive changes here. … Mistakes have led to positive changes
here.
64% 64% 0% 18% -41% 4% -5%
A13 3.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Jones_29.pdf
February 23, 2008 - the
person is being written up, not the
problem.
50 31 62 8 52 25 67 11
3.c Staff worry that mistakes … b (Evidence of a
reporting culture)
1.30 (1.14, 1.47) <0.0001a
Staff worry that mistakes they make … to prevent errors from
happening again.d (Evidence of a learning culture) 1.08 (0.86, 1.36) 0.51
Mistakes … • The odds of a respondent disagreeing in 2007 that they “worry that mistakes they make are
kept … • The odds of respondents working in the laboratory agreeing that “mistakes have led to
positive
-
www.ahrq.gov/sops/surveys/nursing-home/nursing-home-2/index.html
November 01, 2024 - Response to Mistakes. Speaking Up. Staffing. Supervisor Support for Resident Safety. Teamwork.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2024-medical-office-database-report.pdf
January 01, 2024 - (Item F2) 84%
Mistakes happen more than they should in this office. … (Item F3*) 73%
It is just by chance that we don't make more mistakes that affect our
patients. … (Item D11)
82%
Staff are willing to report mistakes they observe in this office. … (Item D12)
80%
Staff feel like their mistakes are held against them. (Item D7*) 64%
6. … (Item E1*)
46%
They overlook patient care mistakes that happen over and over.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2024-medical-office-database-report-rev.pdf
January 01, 2024 - (Item F2) 84%
Mistakes happen more than they should in this office. … (Item F3*) 73%
It is just by chance that we don't make more mistakes that affect our
patients. … (Item D11)
82%
Staff are willing to report mistakes they observe in this office. … (Item D12)
80%
Staff feel like their mistakes are held against them. (Item D7*) 64%
6. … (Item E1*)
46%
They overlook patient care mistakes that happen over and over.
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/connecting-dots-slides.html
December 01, 2017 - Staff worry that mistakes they make are kept in their personnel file.”…always least positive. … Staff feel like their mistakes are held against them. 30%
2. … Staff worry that mistakes they make are kept in their personnel file. 9%
Slide 27
Action Planning … Mistakes have led to positive changes here. 63%
3.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018mosopsdatabasereport-part1.pdf
April 01, 2018 - ,
and mistakes do not happen more than they should. … (F2)
85
Mistakes happen more than they should in this office. … Mistakes happen more than they should in this
office. … Staff feel like their mistakes are held against them. … They overlook patient care mistakes that happen
over and over.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2018mosopsdatabasereport-part1-rev0921.pdf
April 01, 2018 - ,
and mistakes do not happen more than they should. … (F2)
85
Mistakes happen more than they should in this office. … Mistakes happen more than they should in this
office. … Staff feel like their mistakes are held against them. … They overlook patient care mistakes that happen
over and over.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/169-cusp-science-safety-slides.pptx
October 01, 2024 - Use safe design principles to guard against communication mistakes (e.g., misinterpreting ambiguous language … briefings, daily goals)
Independent checks (repeat back to confirm correct understanding)
Learn from mistakes … Prevention | ICU & Non-ICU
The Science of Safety
24
Leading Change
“One of most common leadership mistakes