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www.qualitymeasures.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
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www.qualitymeasures.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
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www.qualitymeasures.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.
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www.qualitymeasures.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.
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www.qualitymeasures.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
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www.qualitymeasures.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
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www.qualitymeasures.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
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www.qualitymeasures.ahrq.gov/teamstepps-program/curriculum/situation/overview/index.html
June 01, 2023 - Ensuring that mistakes or oversights are caught quickly and easily.
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www.qualitymeasures.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
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www.qualitymeasures.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
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www.qualitymeasures.ahrq.gov/sops/about/faq/index.html
June 01, 2022 - Nonpunitive Response to Mistakes.
Organizational Learning. … The composite measures in the community pharmacy survey are:
Communication About Mistakes. … Response to Mistakes.
Staff Training and Skills.
Staffing, Work Pressure, and Pace. … In addition, the community pharmacy survey includes:
Three items about documenting mistakes. … Response to Mistakes.
Management Support for Patient Safety.
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www.qualitymeasures.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/mod2-slides.html
March 01, 2017 - Experiment and take risks by constantly generating small wins and learning from mistakes. … Learn from mistakes.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2015-materials/teamstepps-monthly-webinar-jan2015.pptx
January 01, 2015 - TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS®
Team Dimensional Training
Slide ‹#›
Average Mistakes … Team Dimensional Training
Slide ‹#›
Mental Models Of Teamwork
Communication
Leadership
Correcting Mistakes
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www.qualitymeasures.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.
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www.qualitymeasures.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
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www.qualitymeasures.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/mod2-facguide.html
March 01, 2017 - be prevented in the future
Senior leaders welcome opportunities to learn from setbacks, events or mistakes … based on the principles of safe system design: Simplify the system, create redundancy, and learn from mistakes
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www.qualitymeasures.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
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www.qualitymeasures.ahrq.gov/teamstepps/instructor/reference/teampercept.html
April 01, 2017 - Staff correct each other’s mistakes to ensure that procedures are followed properly.
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www.qualitymeasures.ahrq.gov/teamstepps/officebasedcare/handouts/teamperceptions.html
December 01, 2015 - Staff correct each other’s mistakes to ensure that procedures are followed properly.
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www.qualitymeasures.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