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Showing results for "mistakes".

341. Improving Patient Safety in Nursing Homes: A Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-resource-list-2.0.pdf
     April 01, 2025 - • Teamwork • Staffing • Organizational Learning • Handoffs and Information Exchange • Response to Mistakes … .................................................................................... 4 Response to Mistakes … Response to Mistakes 1. … Resources by Composite Measure Teamwork Staffing Organizational Learning Response to Mistakes

342. Indwelling Urinary Catheter Insertion Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-insertion-notes.docx
     April 01, 2022 - These events evoke a visceral response and serve as a lesson to prevent similar mistakes in the future

343. Learndefects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc
     June 02, 2025 - Most often clinicians recover from mistakes by reducing risks to the patient who suffered a defect.

344. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - Errors Addressed by System Change Medical mistakes caused by latent errors, such as similar sounding … consequences from error-related communications serve to reduce such reporting and limit learning from mistakes … unavoidable and necessary feature of their work.56, 57, 58 It has even been argued that errors and mistakes … needs to be modified so caregivers and their patients feel safe reporting and learning from medical mistakes

345. Final Progress Report:: The National Quality Forum – Annual Meeting 2003 (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/kizer-report.pdf
     January 01, 2024 - Lunch Speaker: Rosemary Gibson, Author, “Wall of Silence: The Untold Story of the Medical Mistakes … That Kill and Injure Millions of Americans” Health consultant Gibson described how medical mistakes … LUNCH Rosemary Gibson, Author, “Wall of Silence: The Untold Story of the Medical Mistakes That Kill

346. Creating an Improvement Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Creating_an_Improvement_Culture_2011_10_01_Transcript.pdf
     January 01, 2011 - The data shows that organizations that are this size and this complex are going to make mistakes. … But when mistakes are made, if the organization demonstrates that they’re sorry, they make it up to the

347. Overview of the Comprehensive Unit-based Safety Program for Application to Mechanically Ventilated Patients: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/overview-cuspmvp-slides.html
     February 01, 2017 - Designed to improve safety culture and help users learn from mistakes.

348. Accessible Facilitator Guide: Designing a Scorecard (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustscorecard_facnotes.docx
     December 01, 2017 - was shared from the perspective of sustainability, teams were instructed to focus on learning from mistakes

349. Designing a Scorecard for Sustainability: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/scorecard-fac-notes.html
     December 01, 2017 - was shared from the perspective of sustainability, teams were instructed to focus on learning from mistakes

350. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/refs.html
     May 01, 2016 - New system for patients to report medical mistakes. New York Times; September 23, 2012. 46.

351. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html
     June 01, 2023 - Patient perceptions of mistakes in ambulatory care. Arch Intern Med  2010;170:1480-1487.

352. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-insertion/unlicensed-staff/scenario-instr.docx
     March 01, 2017 - BLADDER SCAN – POLICY #2202 12/11/06 AHRQ Safety Program for Long-Term Care: HAIs/CAUTI AHRQ Safety Program for Reducing CAUTI in Hospitals Urinary Catheter Types and How To Care for Them Activity Staff Role Play—How good are your catheter care skills? Roleplaying can be a helpful training and educational tool. Rolep…

353. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/intro.html
     September 01, 2015 - Preventing CAUTI in the ICU Setting: Facilitator’s Guide Introduction Previous Page Next Page Table of Contents Preventing CAUTI in the ICU Setting: Facilitator’s Guide Introduction Module 1: Overview Module 2: Urinary Catheter Maintenance Module 3: Conversations Around Device Necessity Mo…

354. Physician Engagement (Transcript) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/engagement.html
     April 01, 2013 - Well, there are a number of ways to do this and some mistakes that we certainly made that I would hopefully … six months at an academic medical center following surgical teams and was trying to tease out which mistakes … That could be progress for reducing infection rates, progress on learning from mistakes, progress on … And I will tell you from my own mistakes, when we started this and our rates of CLABSI at Johns Hopkins

355. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-fac-guide.html
     July 01, 2023 - Work Together To Improve Outcomes Say: System design Humans are fallible and occasionally make mistakes

356. Learn-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-facilitator-guide.docx
     May 01, 2017 - Slide 18 SAY: System design Humans are fallible and occasionally make mistakes, either through inadvertent

357. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-psychological-safety.pdf
     September 01, 2023 - encourages individuals “to express their ideas and concerns, to speak up with questions, and to admit mistakes … program that uses interpersonal relationships to assess and enhance performance; this program recognizes mistakes

358. Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
     March 01, 2016 - Response to Mistakes .................................................... 9 Composite 8. … Response to Mistakes 1. … Response to Mistakes Composite 8.

359. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
     January 01, 2002 - Medical Errors Climate, Stress, and Error in Primary Care 67 likelihood that they would commit mistakes … possible, as Firth-Cozens suggests,1 that stressed physicians are more likely to presume they will make mistakes … The tendency to make mistakes was associated with a lack of emphasis on quality, information, and communication

360. On-line Patient Safety Climate Survey: Tool Development and Lessons Learned (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Connelly.pdf
     January 01, 2003 - went wrong when a sentinel event occurs. 3.10 .611 Agree 13. often blame others for their own mistakes … They further agreed with the statement, “Most people in this MTF often blame others for their own mistakes … willing to discuss what went wrong when a sentinel event occurs. 13. often blame others for their own mistakes