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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-items-composite-measures-english-2.0.pdf
June 05, 2025 - Response to Mistakes
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree, … Staff feel safe reporting mistakes.
A11. Staff are treated fairly when they make mistakes.
A12. … Response to Mistakes
5. Handoffs and Information Exchange
6. Speaking Up
7.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/nursing-home/2025-nursing-home-database-report-appendix.pdf
January 01, 2025 - 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
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/2019-nhsops-dbreport-partii.pdf
January 01, 2019 - Staff are afraid to report their mistakes. (A12R) 51% 58%
3. … This nursing home lets the same mistakes happen again and
again. … Staff are afraid to report their mistakes. (A12R) 55% 56%
3. … Staff are afraid to report their mistakes. (A12R) 56% 57% 55%
3. … Nonpunitive Response to Mistakes 60% 56% 54% 55% 60%
11.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-survey-english.pdf
June 02, 2025 - 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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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/MO_Items-Composite_Measures.pdf
June 02, 2025 - Staff feel like their mistakes are held against them. (negatively worded)
D8. … Staff are willing to report mistakes they observe in this office. … Our office processes are good at preventing mistakes that could affect patients.
F3. … Mistakes happen more than they should in this office. (negatively worded)
F4. … It is just by chance that we don’t make more mistakes that affect our patients.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
June 02, 2025 - 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
-
www.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
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
June 02, 2025 - Mistakes have led to positive changes here.
A13. … It is just by chance that more serious mistakes don't happen around here. (negatively worded)
A17. … Staff feel like their mistakes are held against them. (negatively worded)
A12. … Staff worry that mistakes they make are kept in their personnel file.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/amermanslides.pdf
June 02, 2025 - Things Learned
• Team-oriented store
– Much more organized
– Did a better job at preventing mistakes … team-oriented store
– Unorganized, cluttered
– Less effective communication
– Worried about the mistakes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/facilitator-notes.docx
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 24
SAY:
A system of Just Culture recognizes that people make mistakes.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
June 02, 2025 - Staff feel like their mistakes are held against them ................................... 1 2 3 4 … Mistakes have led to positive changes here .............................................. 1 2 3 4 … 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 ......... 1 2 3 4 5
17. … SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-7-e.pdf
June 02, 2025 - 68.9% .54
Doctor-child communication 66.3% 70.0% .07
Involving teens in care 70.7% 77.9% .007
Mistakes … 68.3% .20
Doctor-child communication 67.0% 69.4% .22
Involving teens in care 72.5% 76.2% .14
Mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-6-a.pdf
June 02, 2025 - .74
Nurse-child communication .77
Doctor-child communication .84
Involving teens in care .66
Mistakes … Nurse-child communication 3 .88
Doctor-child communication 3 .90
Involving teens in their care 3 .71
Mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 02, 2025 - 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
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2023-child-hcahps-infographic.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
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-7-b.pdf
June 02, 2025 - Doctor-child communication 66.4% 67.0% 66.4% .94
Involving teens in care 71.7% 71.5% 68.8% .75
Mistakes … Doctor-child communication 65.2% 66.8% 67.8% .44
Involving teens in care 70.6% 70.7% 70.7% 1.00
Mistakes
-
www.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
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
June 02, 2025 - 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
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
June 02, 2025 - 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
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
September 01, 2009 - Mistakes have led to positive changes here.
A13. … It is just by chance that more serious mistakes don't happen around here. … In other words, the reason mistakes do not happen more often is
good luck, NOT because procedures or … Staff feel like their mistakes are held against them. (negatively worded)
A12. … Staff worry that mistakes they make are kept in their personnel file.