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www.ahrq.gov/evidencenow/tools/keydrivers/description.html
October 01, 2020 - they frequently encounter problems such as large amounts of missing data, documentation errors, or mistakes … Leaders should find ways to overcome the reluctance of practice members to admit mistakes, doubts, or … As with patient safety, leaders want to establish a blame-free atmosphere where mistakes are considered
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-ch-hospital-webcast-122223-toomey.pdf
December 01, 2022 - Child:
How well nurses communicate with your child
70%
Attention to Safety and Comfort:
Preventing mistakes
-
www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/sim-tool-guidance.html
July 01, 2023 - Encourage participants to not be afraid to make mistakes.
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module7-presenters-notes.pdf
January 01, 2008 - what is going on around you and with you
• Cross-Monitoring
• Watching each other's backs
• Ensuring mistakes … It involves watching each other's backs and ensuring mistakes/oversights are
caught.
-
www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module7-all-together.pptx
January 01, 2008 - assessing what is going on around you and with you
Cross-Monitoring
Watching each other's backs
Ensuring mistakes … It involves watching each other's backs and ensuring mistakes/oversights are caught.
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/member-survey-nw.pdf
January 01, 2014 - practice (select only one
response):
Strongly disagree Disagree Neutral Agree Strongly agree
Mistakes … change in our
practice
This practice is a place of joy and
hope
This practice learns from its mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/key_drivers_descriptions.pdf
February 01, 2019 - they frequently encounter problems
such as large amounts of missing data, documentation errors, or mistakes … Leaders
should find ways to overcome the reluctance of practice members to admit mistakes, doubts, … As with patient safety, leaders want
to establish a blame-free atmosphere where mistakes are considered
-
www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
January 01, 2024 - Feedback—Based on the mistakes uncovered in step 5 and the information learned in step 6, improve the
-
www.ahrq.gov/hai/cusp/modules/understand/alt-text.html
July 01, 2018 - People are fallible
Medicine is still treated as an art, not a science
Systems do not catch mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/overview-cuspmvp-slides.pptx
January 01, 2017 - Designed to improve safety culture and help users learn from mistakes
Values the wisdom of frontline
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/CHIPRA_1415-P010-1-EF.pdf
March 01, 2015 - 0.74
Nurse-child communication 0.77
Doctor-child communication 0.84
Involving teens in care 0.66
Mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
May 01, 2011 - PowerPoint Presentation
Communication and Optimal Resolution
(CANDOR)
Toolkit
Module 6: Care for the Caregiver
Module 6 includes information on the Care for the Caregiver component of the CANDOR process, which focuses on providing emotional support to caregivers following a CANDOR event. This module includes steps…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
June 02, 2025 - These conditions are the mistakes that occur without human error. … Sensemaking is a way for a unit to learn from and prevent mistakes.
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-slides.html
March 01, 2017 - Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Slide 1: Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles
Slide 2: Objectives
Describe the purpose of the Long-Ter…
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simtool_guidance.docx
May 01, 2017 - .
· Encourage participants to not be afraid to make mistakes.
· If there are other observers besides
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-nh_webcast-famolaro.pdf
September 21, 2022 - Composite Measure Results
46%
55%
56%
63%
% Positive Response
Handoffs
Nonpunitive Response to
Mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
May 01, 2017 - Errors associated with failures of
attentional behavior are labeled “mistakes”
and often occur because … Most errors in health
care are slips rather than mistakes.
-
www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - Learning From Defects Through Sensemaking: Slide Presentation
AHRQ Safety Program for Surgery
Slide 1: AHRQ Safety Program for Surgery—Implementation
Learning From Defects through Sensemaking
Slide 2: Learning Objectives
Describe difference between first-order and second-order problem-solving.
L…
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-care/slides.html
March 01, 2017 - Self-correcting and helping others correct their mistakes.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
January 01, 2004 - Originally designed “to provide a forum for physicians to confess
their mistakes and help their colleagues … Minimizing medical mistakes: the art
of medical decisionmaking. … Internal bleeding: the
truth behind America’s terrifying epidemic of medical
mistakes.