-
www.ahrq.gov/cahps/surveys-guidance/hospital/about/child-survey-measures.html
May 01, 2016 - the hospital
Q47 Provider talked with teen about care after leaving the hospital
Preventing Mistakes … Providers checked child's identity before giving medicines
Q30 Providers told parent how to report mistakes
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2022-MOSOPS-Database-Report-Part-II-508.pdf
January 01, 2022 - (Item D11) 82% 75%
Staff are willing to report mistakes they observe in this office. … (Item D12) 79% 74%
% Rarely/Never
Staff feel like their mistakes are held against them. … (Item E1*) 46% 34%
They overlook patient care mistakes that happen over and over. … (Item E1*) 46% 44% 46% 50%
They overlook patient care mistakes that happen over and over. … (Item E1*) 42% 45% 44% 31%
They overlook patient care mistakes that happen over and over.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2020_MOSOPS_Part_II_508.pdf
January 01, 2020 - They overlook patient care mistakes that happen over and over. … Mistakes happen more than they should in this office. … Staff feel like their mistakes are held against them. … Mistakes happen more than they should in this office. … Staff feel like their mistakes are held against them.
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www.ahrq.gov/teamstepps-program/resources/additional/cross-monitor.html
July 01, 2023 - involves monitoring actions of other team members, providing a safety net within the team, ensuring that mistakes
-
www.ahrq.gov/news/newsroom/case-studies/ktcquips36.html
October 01, 2014 - master trainers, reports that the hospital staff are using TeamSTEPPS techniques and learning from both mistakes … Between 2007 and 2009, the survey scores improved in one key area; the scores on the "mistakes have led
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2024-child-hcahps-chartbook.pdf
January 01, 2024 - their
child's care with doctors, nurses, and
other providers
Low Scoring
Measures
Preventing Mistakes … always checked their child's Identity
before giving them medicines and told
them how to report mistakes … new medicines after
leaving the hospital
Low Scoring Items
Providers Told
Parents How to
Report Mistakes … 33%
of respondents reported providers told
parent how to report mistakes
Asked About Things … The lowest scoring measures were
Preventing Mistakes and Helping You Report Concerns (62 percent), and
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/nh-survey.doc
June 09, 2016 - Staff are afraid to report their mistakes
(1
(2
(3
(4
(5
(9
13. … Staff are treated fairly when they make
mistakes
(1
(2
(3
(4
(5
(9
16. … Staff feel safe reporting their mistakes
(1
(2
(3
(4
(5
(9
SECTION B: Communications
How often … This nursing home lets the same mistakes happen again and again
(1
(2
(3
(4
(5
(9
SECTION D:
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/physician-survey-post-intervention-nw.pdf
January 01, 2014 - your practice (select one for
each row):
Strongly
disagree
Disagree Neutral Agree Strongly
agree
Mistakes … practice
This practice is a place of joy and hope
This practice learns from its mistakes … field 1 of 4:
Year field 2 of 4:
Year field 3 of 4:
Year field 4 of 4:
Name of your practice:
Mistakes … work: Off
It's hard to get things to change: Off
This is a place of joy and hope: Off
Learns from mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-060314.pptx
March 01, 2009 - Comprehensive Unit-based Safety Program
An intervention to improve teamwork and safety culture and learn from mistakes … as ‘soft’
Vehicle for clinical change
Principles: Science of Safety
30
Accept that we will make mistakes … others do
Create clear goals, ask questions early
Standardize, create independent checks, and learn from mistakes … system
We need to provide a safe space to voice what we see
CUSP is a structured approach to learn from mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/Part-II-SOPS-ASC-DatabaseReport.pdf
December 01, 2021 - Response to Mistakes % Agree/Strongly Agree
Staff are treated fairly when they make mistakes. … Response to Mistakes % Agree/Strongly Agree
Staff are treated fairly when they make mistakes. … Response to Mistakes 88% 97% 80% 93% 95% 84% 81% 78% 79%
7. … Response to Mistakes % Agree/Strongly Agree
Staff are treated fairly when they make mistakes. … Response to Mistakes % Agree/Strongly Agree
Staff are treated fairly when they make mistakes.
-
www.ahrq.gov/hai/cusp/toolkit/content-calls/framework-slides/slides.html
October 01, 2014 - Step 4: Learning from Mistakes
Slide 28. … Learn from mistakes.
Evaluate:
Feedback performance. … An intervention to learn from mistakes and improve safety culture. … Learn from mistakes.
Apply strategies to both technical work and teamwork. … Step 4: Learning from Mistakes
What happened?
Why did it happen (system lenses)?
-
www.ahrq.gov/sites/default/files/wysiwyg/cahps/cahps-database/2023-child-hcahps-chartbook.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 … The lowest scoring measures were
Preventing Mistakes and Helping You Report Concerns (61 percent), and … (Page 4 of 4)
Attention to Safety and Comfort Measures
Composite Measure/Item Name
Preventing Mistakes … (Q29)
• Never
• Sometimes
• Usually
• Always
Mistakes in your child’s healthcare can include things
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018mosopsdatabasereport-part2.pdf
April 01, 2018 - They overlook patient care mistakes that happen over and
over. … Mistakes happen more than they should in this office. … Staff feel like their mistakes are held against them. … They overlook patient care mistakes that happen over and
over. … They overlook patient care mistakes that happen over
and over.
-
www.ahrq.gov/sites/default/files/2025-02/nance-report.pdf
January 01, 2025 - standard of full, immediate disclosure of injuries to
patients (when such injuries involve medical mistakes … across the spectrum of American healthcare so as to rapidly learn from errors and
omissions as well as mistakes … as well as practice problems supporting such mistakes. … make a victim whole with money; on the other hand is the concept that
injuries arising from medical mistakes … If our goal as a society is to extract as much clinical information from errors and
mistakes as possible
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
June 12, 2008 - have legislation
requiring reporting systems, The Joint Commission requires that hospitals report mistakes … For example, most
taxonomies include mistakes (e.g., prescribing errors) and the outcome of mistakes … Without lenses to see process maps and the factors (e.g., teamwork,
supervision) that contribute to mistakes … For example,
mistakes involving central line placement are common, costly, and distributed among multiple … Many
types of mistakes commonly occur across institutions that would benefit from a central method
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/staff-survey-6mon-post-intervention-nw.pdf
August 23, 2018 - practice (select one for each row):
Strongly
disagree
Disagree Neutral Agree Strongly
agree
Mistakes … practice
This practice is a place of joy and hope
This practice learns from its mistakes
-
www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - These mistakes sometimes result in no harm, while other times they may result in additional or prolonged … These types of mistakes are called medical errors. 16
This definition is clearly worded and coherent … In hospital settings, this shift in terminology from mistakes/errors to feeling safe roughly doubled … Framing experiences in terms of “mistakes” is more approachable than framing as “diagnostic errors,” … Respondents should be encouraged to report on both mistakes and diagnostic problems.
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
June 01, 2023 - These mistakes sometimes result in no harm, while other times they may result in additional or prolonged … These types of mistakes are called medical errors. 16
This definition is clearly worded and coherent … In hospital settings, this shift in terminology from mistakes/errors to feeling safe roughly doubled … Framing experiences in terms of “mistakes” is more approachable than framing as “diagnostic errors,” … Respondents should be encouraged to report on both mistakes and diagnostic problems.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/nh-survey.pdf
June 06, 2018 - Staff are afraid to report their mistakes .......... 1 2 3 4 5 9
13. … Staff are treated fairly when they make
mistakes.................................................. … Staff feel safe reporting their mistakes ........... … This nursing home lets the same mistakes
happen again and again ................................
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-slides.html
July 01, 2018 - Comprehensive Unit-based Safety Program
An intervention to improve teamwork and safety culture and learn from mistakes … for clinical change
Slide 30
Principles: Science of Safety
Accept that we will make mistakes … Create clear goals, ask questions early
Standardize, create independent checks, and learn from mistakes … We need to provide a safe space to voice what we see
CUSP is a structured approach to learn from mistakes