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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/about/child_hcaps_measures_909.pdf
May 11, 2016 - teens in their care (composite of 3 items)
Topic: Attention to Safety and Comfort
• Preventing mistakes … with teen about care after leaving the hospital
Topic: Attention to Safety and Comfort
Preventing Mistakes … checked the child’s identity before giving medicines
and whether providers told the parent how to report mistakes … Response Options
• Never
• Sometimes
• Usually
• Always
Q30 Providers told parent how to report mistakes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
January 01, 2017 - In order to do this effectively, providers must develop or improve the ability to learn from mistakes … Errors also occur because systems frequently are not designed to catch mistakes before they reach the
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-slides.pptx
September 26, 2023 - Culture of Safety
Safety values and practices are used to prevent harm and learn from mistakes. … Pre-Decisional Deliberative Document
Internal VA Use Only
“I am comfortable identifying and reporting mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-ASC-webcast-2023-0509-hare.pdf
January 01, 2023 - Staff Training (4 items)
• Organizational Learning – Continuous Improvement (3 items)
• Response to Mistakes … SOPS ASC Database
Composite Measure Results
Average % Positive Response
Teamwork 88%
Response to Mistakes
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-transcript.html
December 01, 2017 - And as I said, it's an intervention to improve teamwork and safety culture, and also to learn from mistakes … It says important to accept that we will make mistakes. … So as long as we need to keep in mind that fact and realize hat we will make mistakes. … We accept that we'll make mistakes. … And finally, remembering that we need to standardize, create independent checks, and learn from mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-transcript.doc
June 03, 2014 - And as I said, it’s an intervention to improve teamwork and safety culture, and also to learn from mistakes … It says important to accept that we will make mistakes. … So as long as we need to keep in mind that fact and realize that we will make mistakes. … We accept that we’ll make mistakes. … And finally, remembering that we need to standardize, create independent checks, and learn from mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
May 01, 2003 - shown, however, that most physicians do not know
how to appropriately address the issue of medical mistakes … Conventional training and practice in health care, especially in medicine,
continue to attribute mistakes … Coping with
medical mistakes and errors in judgment. Ann Emerg
Med 2002;39(3):287–92.
12. Wu A.
-
www.ahrq.gov/hai/cusp/toolkit/content-calls/business-case.html
April 01, 2013 - , this can be operational mistakes. … Conversely, if you let mistakes and errors creep in and your volume goes down because you’re taking longer … If you improve quality by doing anything, whether it’s infections or medication mistakes or patient falls … But you’ve got infections, you’ve got medication mistakes, patients falls, whatever it is, blocking them … And so the delays, the gaps between the cars are the mistakes and errors we make that you can get rid
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-tpq-questionnaire.pdf
June 02, 2025 - Staff correct each other’s mistakes to
ensure that procedures are followed
properly.
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-t-taq-questionnaire.pdf
June 02, 2025 - Effective leaders view honest mistakes as
meaningful learning opportunities.
10.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stock_72.pdf
January 01, 2007 - solution was due to item 1
(“The culture of this clinic makes it easy to learn from the medication mistakes … The culture of this clinic makes it easy to learn from the medication
mistakes of others.
2. … In this clinic we have defined protocols about reporting and
discussing medication mistakes that almost … This is reinforced by moderately high loading of item 12 (mistakes not approached
as personal blame)
-
www.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
March 01, 2024 - patient-reported diagnostic process-related breakdowns” framework can help organizations learn from mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
June 02, 2025 - experienced provider is influenced by the environment in which he or she works and can be responsible for mistakes … As a result, providers must increase their ability to learn from mistakes and implement procedures to … Errors also occur because systems frequently do not catch mistakes before they reach the patient.
-
www.ahrq.gov/research/publications/search.html?page=16
September 01, 2012 - errores médicos
AHRQ consumer health fact sheet in Spanish on protecting yourself from healthcare mistakes
-
www.ahrq.gov/hai/tools/mvp/modules/cusp/physician-staff-engagement-slides.html
March 01, 2017 - Slide 3: Leading Change 1
"One of most common leadership mistakes is expecting technical solutions … Attribute mistakes to the system rather than the provider?
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-centered-care-slides.html
December 01, 2017 - Comprehensive Unit-based Safety Program
An intervention to learn from mistakes and improve safety culture … including patients and families to share their voice
CUSP is a structured approach to learn from mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/module-2-slides.pptx
March 01, 2017 - Experiment and take risks by constantly generating small wins and learning from mistakes. … Prevention
11
Challenge the Process
Seek innovative ways to change, grow, and improve
Learn from mistakes
-
www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2014/mosurv14notes.html
June 01, 2014 - For example, for the item "Mistakes happen more than they should in this office," if 60 percent of respondents … item-level percent positive response would be 80 percent (i.e., 80 percent of respondents do not believe mistakes
-
www.ahrq.gov/research/findings/final-reports/index.html?page=21
January 01, 2024 - Human and Environmental Factors Publication Date: June 2004
Creating Learning Cultures Around Mistakes
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
December 01, 2017 - Education can make people aware of the problem, but it alone will not eliminate mistakes. … Implement constraints that prevent mistakes. These are the strongest types of interventions.