-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/pharmsops-composites.pdf
June 19, 2018 - Staff in this pharmacy discuss mistakes.
B13. … Staff are treated fairly when they make mistakes.
C4. … Staff feel like their mistakes are held against them. … This pharmacy is good at preventing mistakes.
C9. … Communication About Mistakes
9. Response to Mistakes
10.
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/brownslides.pdf
August 13, 2015 - 89%
81%
Teamwork 86%
81%
40
40
Survey Results
Staff Training 78%
79%
Response to Mistakes … Communication Openness
Staffing, Work Pressure and Pace
Staff Training
Response to Mistakes … • 78% positive for DHC vs 82% for pilot ASCs
Staff are treated fairly when they
make mistakes. … 81%
89%
Learning, rather than blame, is
emphasized when mistakes are
made.
78%
70%
Staff … : Continued treating
mistakes as learning opportunities
49
49
Going Forward
• Continue to collaborate
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
November 15, 2019 - Staff feel like their mistakes are held against them
(1
(2
(3
(4
(5
9. … Mistakes have led to positive changes here
(1
(2
(3
(4
(5
10. … It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … Staff worry that mistakes they make are kept in their personnel file
(1
(2
(3
(4
(5
17. … 2
(3
(4
(5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/motzslides.pdf
May 12, 2014 - work to do:
– Processes for exchanging
information across shifts
– Staff in the pharmacy
discuss mistakes … – We talk about ways to
prevent mistakes from
happening again
– Mistakes have led to
positive
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-6-b.pdf
December 29, 2017 - giving medications
.21 .26 .02 .15 .24 .27 .18 .16 .66
Q29
Providers told parent how
to report mistakes … questions about readiness to leave .68
Q46 Provider talked with teen about care after discharge .58
Mistakes … Providers checked child ID before giving medications .25
Q29 Providers told parent how to report mistakes … communication .76 .81 .52 .77 .72 .76
(8) Involving teens in care .53 .55 .44 .57 .52 .65 .51
(9) Mistakes … .58
Nurse-child communication .56
Doctor-child communication .51
Involving teens in care .39
Mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - Staff feel like their mistakes are held against them
(1
(2
(3
(4
(5
9. … Mistakes have led to positive changes here
(1
(2
(3
(4
(5
10. … It is just by chance that more serious mistakes don’t happen around here
(1
(2
(3
(4
(5
11. … Staff worry that mistakes they make are kept in their personnel file
(1
(2
(3
(4
(5
17. … (5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the following mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-6-a.pdf
December 29, 2017 - .74
Nurse-child communication .77
Doctor-child communication .84
Involving teens in care .66
Mistakes … Nurse-child communication 3 .88
Doctor-child communication 3 .90
Involving teens in their care 3 .71
Mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-7-e.pdf
December 29, 2017 - 68.9% .54
Doctor-child communication 66.3% 70.0% .07
Involving teens in care 70.7% 77.9% .007
Mistakes … 68.3% .20
Doctor-child communication 67.0% 69.4% .22
Involving teens in care 72.5% 76.2% .14
Mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
December 22, 2017 - Staff feel like their mistakes are held against them ................................... … Mistakes have led to positive changes here .............................................. … It is just by chance that more serious mistakes don’t happen around
here ......................... … Staff worry that mistakes they make are kept in their personnel file ......... … 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the following mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
March 22, 2017 - Staff feel like their mistakes are held against them ................................... … Mistakes have led to positive changes here .............................................. … It is just by chance that more serious mistakes don’t happen around
here ......................... … Staff worry that mistakes they make are kept in their personnel file ......... … 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the following mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-7-b.pdf
December 29, 2017 - Doctor-child communication 66.4% 67.0% 66.4% .94
Involving teens in care 71.7% 71.5% 68.8% .75
Mistakes … Doctor-child communication 65.2% 66.8% 67.8% .44
Involving teens in care 70.6% 70.7% 70.7% 1.00
Mistakes
-
www.monahrq.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html
March 01, 2017 - A Just Culture is one that allows teams to learn from mistakes in a safe environment. … In failure, you are given an opportunity to learn from your mistakes and continue to improve processes … System design
Humans are not perfect and occasionally make mistakes, either through unintentional errors … All humans make mistakes, and it is important to differentiate between human error and at-risk behavior … Slide 25: A Just Culture
Say:
A system of Just Culture recognizes that people make mistakes.
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-7-c.pdf
December 29, 2017 - 75.2% 71.3% 68.8% 64.1% 59.2% <.001
Involving teens in care 75.3% 76.0% 71.3% 68.8% 66.2% <.001
Mistakes … 74.4% 71.8% 69.5% 64.1% 58.9% <.001
Involving teens in care 75.0% 76.7% 72.2% 68.7% 64.9% <.001
Mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-7-d.pdf
December 29, 2017 - communication 65.8% 65.8% 73.1% 72.1% 70.3% <.001
Involving teens in care 70.2% 71.4% 73.6% 77.1% 74.0% .13
Mistakes … communication 65.6% 66.6% 71.5% 71.1% 72.2% <.001
Involving teens in care 70.7% 71.6% 73.0% 75.6% 75.4% .33
Mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-7-a.pdf
December 29, 2017 - 66.7% 72.3% 70.1% 65.2% 65.7% <.001
Involving teens in care 64.4% 69.3% 70.6% 75.9% 70.3% 73.2% .08
Mistakes … 67.7% 71.4% 71.1% 65.6% 66.6% <.001
Involving teens in care 65.3% 69.2% 71.4% 74.2% 70.1% 73.5% .30
Mistakes
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/2024-medical-office-database-report-appendix.pdf
January 01, 2024 - (Item D11) 82% 81%
Staff are willing to report mistakes they observe in this office. … (Item D12) 81% 77%
% Never/Rarely
Staff feel like their mistakes are held against them. … (Item E1*) 46% 44%
They overlook patient care mistakes that happen over and over. … (Item E1*) 48% 44% 49% 35%
They overlook patient care mistakes that happen over and over. … (Item E1*) 45% 47% 46% 28%
They overlook patient care mistakes that happen over and over.
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/part-ii-sops-asc-database-report.pdf
January 01, 2020 - Response to Mistakes
1. Staff are treated fairly when they make mistakes. … Response to Mistakes
1. Staff are treated fairly when they make mistakes. … Response to Mistakes 89% 95% 79% 91% 94% 80% 76% 78% 77%
7. … Response to Mistakes
1. Staff are treated fairly when they make
mistakes. … Response to Mistakes
1. Staff are treated fairly when they make mistakes.
-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/easy-to-understand-telehealth-consent-form.docx
April 15, 2020 - (We don’t know if mistakes are more common with telehealth visits.)
· Your provider may decide you still
-
www.monahrq.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.monahrq.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