-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-2-presentation.pdf
May 01, 2007 - My supervisor emphasizes learning rather than blame when staff
make mistakes.
2.
-
www.innovations.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
August 01, 2022 - greatest impediment to error prevention in the medical industry is 'that we punish people for making mistakes … Many health care systems reinforce a focus on individual behaviors designed to prevent mistakes and fail … to recognize the impact of faulty systems, processes, and conditions that lead people to make mistakes
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module1/1_ts_office_intro-ig.pptx
January 20, 2006 - In effective teams, mistakes are caught, addressed, and resolved before they compromise patient safety … know and experience firsthand the confusion, miscommunications and uncoordinated care that lead to mistakes
-
www.innovations.ahrq.gov/questions/resources/index.html
November 01, 2020 - families who engage with health care providers to ask good questions can help reduce the chance of mistakes
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/staff-survey-mw.pdf
January 01, 2014 - Mistakes have led to positive changes
here 1 2 3 4 5
4. … This practice learns from its mistakes 1 2 3 4 5
13.
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/staff-survey-post-intervention-va.pdf
February 23, 2018 - Mistakes have led to positive changes here
B. I have many opportunities to grow in my work
C. … This practice learns from its mistakes
K.
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-transcript-508-compliant.pdf
June 01, 2017 - Well, we define it as the
extent to which staff feel that their mistakes and event reports are not held … against them, and that mistakes are
not kept in their personnel file. … And these three items
are staff feel like their mistakes are held against them; when an event is reported … it feels like this person is being
written up, not the problem; staff worry that mistakes they make … How does Just Culture
address the item staff worry that mistakes they make are kept in their personnel
-
www.innovations.ahrq.gov/questions/resources/diagnosis/step5.html
November 01, 2020 - Remember, being an active member of your health care team helps to reduce your chances of medical mistakes
-
www.innovations.ahrq.gov/teamstepps-program/curriculum/team/tools/debrief.html
December 01, 2023 - Debriefs are most effective when conducted in an environment where mistakes are viewed as learning opportunities
-
www.innovations.ahrq.gov/teamstepps-program/curriculum/situation/overview/index.html
June 01, 2023 - Ensuring that mistakes or oversights are caught quickly and easily.
-
www.innovations.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
December 01, 2017 - Basic Principles of Safe Design
Standardize
Create independent checks for key process
Learn from mistakes … Slide 81
Learn from Defects
As one of the principles of safe design—we need to learn from our mistakes
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast4-yount.pdf
August 02, 2018 - we have to
double document information such as vitals, pain
intake and output, that could lead to mistakes
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/member-survey-baseline-nc.pdf
January 01, 2014 - Mistakes have led to positive changes here. O O O O O
2. … This practice learns from its mistakes. O O O O O
11.
-
www.innovations.ahrq.gov/research/findings/final-reports/index.html?page=8
August 01, 2004 - (s): Patient Safety Tools Publication Date: August 2004
Creating Learning Cultures Around Mistakes
-
www.innovations.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
August 01, 2022 - Caregiver
Module 7: Resolution
Module 8: Organizational Learning and Sustainability
“We realize mistakes
-
www.innovations.ahrq.gov/teamstepps/officebasedcare/handouts/teamperceptions.html
December 01, 2015 - Staff correct each other’s mistakes to ensure that procedures are followed properly.
-
www.innovations.ahrq.gov/teamstepps/instructor/reference/teampercept.html
April 01, 2017 - Staff correct each other’s mistakes to ensure that procedures are followed properly.
-
www.innovations.ahrq.gov/teamstepps/officebasedcare/module1/office_intro-ig.html
September 01, 2015 - In effective teams, mistakes are caught, addressed, and resolved before they compromise patient safety … know and experience firsthand the confusion, miscommunications and uncoordinated care that lead to mistakes
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/userguide/ascguide.pdf
April 01, 2015 - , and staff are treated fairly when
they make mistakes.
8. … Staff are treated fairly when they make mistakes ...... 1 2 3 4 5 9
3. … Learning, rather than blame, is emphasized when
mistakes are made ................................... … Staff are treated fairly when they make mistakes.
C4. … Learning, rather than blame, is emphasized when mistakes are made.
C5.
-
www.innovations.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/questionnaire-overview.pdf
March 20, 2017 - the Questionnaire
Document No. 950
Page 3
Attention to Safety and Comfort:
• Preventing mistakes … checked
child’s identity before
giving medicines
-- 29 --
Providers told parents
how to report mistakes