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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
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www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.html
June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors
Past Research on Patient Perceptions of Safety and Diagnostic Mishaps
Previous Page Next Page
Table of Contents
Patient Experience as a Source for Understanding the Origins, Impact, and Remedia…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.html
June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors
Past Research on Patient Perceptions of Safety and Diagnostic Mishaps
Previous Page Next Page
Table of Contents
Patient Experience as a Source for Understanding the Origins, Impact, and Remedia…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
January 01, 2017 - Presentation: Program Overview
Learn From Defects in Care of Mechanically Ventilated Patients
AHRQ Safety Program for Mechanically Ventilated Patients
AHRQ Pub. No. 16(17)-0018-34-EF
January 2017
Learn From Defects ‹#›
AHRQ Safety Program for Mechanically Ventilated Patients
1
Learning Objectives
After this ses…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support.pptx
July 01, 2023 - Often we are already aware of our limitations, shortcomings, and mistakes. … People can feel targeted and embarrassed when their mistakes are pointed out in public, and they may … Recognize that we are all trying to do the best we can and making mistakes is hard on us.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_5-mutual-support-speaker-notes.pdf
July 01, 2023 - Often we are already aware of our
limitations, shortcomings, and mistakes. … People can
feel targeted and embarrassed when their mistakes are pointed out in public,
and they may … Recognize that we are all trying to do the best we can and making
mistakes is hard on us.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
June 05, 2008 - • Collecting and analyzing data on medical errors to determine whether there are areas where
mistakes … Media mistakes in coverage of the Institute
of Medicine’s error report.
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www.ahrq.gov/health-literacy/improve/pharmacy/guide/train2.html
September 01, 2020 - Anecdotal evidence of making mistakes with their medications and experiencing more adverse drug events
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/applycusp.pptx
August 18, 2011 - (“Apply CUSP” cover slide with CUSP Toolkit logo)
1
Learning Objectives
Review key steps of the CUSP Toolkit
Learn how Just Culture principles can augment CUSP
2
Introduce Just Culture principles
2
Introduction to Just Culture Principles
3
3
Understand Just Culture
4
4
Just Culture1
A system t…
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www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
December 01, 2012 - System design
Humans are fallible and occasionally make mistakes, either through inadvertent errors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdf
May 01, 2017 - Slide 18
SAY:
System design
Humans are fallible and occasionally make
mistakes, either through inadvertent
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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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3j.docx
January 29, 2013 - 3J: Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire, and Confusion Assessment Method
Background: Patients found to have impaired mental activity as a risk factor for falls require further evaluation. The Delirium Evaluation Bundle is designed to help determine if the patient has delir…
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www.ahrq.gov/talkingquality/distribute/promote/timing.html
March 01, 2016 - Timing Promotion of a Quality Report for Maximum Impact
As part of the initial planning of your promotional campaign, one critical consideration is the timing of your activities. Most health care decisions that can be influenced by comparative quality reports happen for different people at different times.
…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-insertion/unlicensed-staff/scenarios-instr.html
March 01, 2017 - Urinary Catheter Types and How To Care for Them Activity
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Staff Role Play—How good are your catheter care skills?
Roleplaying can be a helpful training and educational tool. Roleplaying allows staff to actively practice the skills they are learni…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
October 01, 2014 - Module 3: Falls Prevention and Management
Session 1
Previous Page Next Page
Table of Contents
Module 3: Falls Prevention and Management
Learning and Performance Objectives
Session 1
Session 2
Conclusion
Appendix. Additional Tools and Resources
Introduction
Case Study: Mr.…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.doc
August 08, 2012 - Most often clinicians recover from mistakes by reducing risks to the patient who suffered a defect.
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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
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www.ahrq.gov/patient-safety/reports/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.
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www.ahrq.gov/health-literacy/professional-training/shared-decision/tool/resource-3.html
September 01, 2020 - their choice does not, however, mean a qualified medical interpreter cannot be present to make sure no mistakes