-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/about/child-hcahps-english-survey-954a.pdf
May 12, 2016 - Mistakes in your child’s health care can
include things like giving the wrong
medicine or doing the … stay, did providers or
other hospital staff tell you how to report if
you had any concerns about mistakes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/Part-I-SOPS-ASC-DatabaseReport.pdf
December 01, 2021 - improve
patient safety and makes changes to ensure that
problems do not recur.
3
Response to Mistakes … safety problems,
learning rather than blame is emphasized, and
staff are treated fairly when they make mistakes … Response to Mistakes 86% 9.62% 49% 74% 81% 87% 92% 96% 100%
7. … Response to Mistakes % Agree/Strongly Agree
Staff are treated fairly when they make mistakes. … (Item C2) 85% 10.39% 40% 71% 79% 86% 93% 97% 100%
Learning, rather than blame, is emphasized when mistakes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/microbiologic-specimens-slides.pptx
June 01, 2021 - Avoided the mistakes that were made in the respiratory collection process?
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2022-hsops2-database-report.pdf
January 01, 2022 - Learning—Continuous
Improvement
Work processes are regularly reviewed, changes are made
to keep mistakes … Reporting Patient Safety Events Mistakes of the following types are reported: (1) mistakes
caught and … corrected before reaching the patient and (2)
mistakes that could have harmed the patient but did not … Response to Error Staff are treated fairly when they make mistakes and there
is a focus on learning … from mistakes and supporting staff
involved in errors.
-
www.qualitymeasures.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6p-service-recovery.html
April 01, 2022 - Axiom 4: Customers react more strongly to "fairness mistakes" than "honest mistakes."
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
June 01, 2021 - Slide 5
Swiss Cheese Model
SAY:
Let’s return to our “Swiss cheese model” to help visualize where mistakes … Sharing and understanding our previous mistakes helps everyone improve!
-
www.qualitymeasures.ahrq.gov/cahps/surveys-guidance/hospital/about/child_hp_survey.html
February 01, 2024 - Involving teens in their care (composite measure)
Attention to Safety and Comfort
Preventing mistakes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
May 01, 2017 - These conditions are the mistakes that occur without human error. … Sensemaking is a way for a L&D unit to learn from and prevent mistakes.
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
April 01, 2022 - Errors often occur because systems frequently are not designed to catch mistakes before they reach the … someone to be more careful is a far weaker intervention because humans are fallible and are bound to make mistakes
-
www.qualitymeasures.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/overview.html
March 01, 2017 - Nonpunitive Response to Mistakes
Applying Safety Principles
Senior Leader Engagement
Staff
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-august2016.pptx
January 01, 2016 - Safety Culture
Slide ‹#›
Comprehensive Unit Based Safety Program (CUSP)
An intervention to learn from mistakes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-facilitator-guide.docx
May 01, 2017 - Slide 18
SAY:
System design
Humans are fallible and occasionally make mistakes, either through inadvertent
-
www.qualitymeasures.ahrq.gov/questions/resources/diagnosis/step3.html
November 01, 2020 - Being an active member of your health care team also helps to reduce your chances of medical mistakes
-
www.qualitymeasures.ahrq.gov/teamstepps/events/webinars/jan-2017.html
January 01, 2017 - Fear of Making Mistakes/Errors Slide 39. Frame Errors Positively Slide 40. … Return to Contents
Slide 38
Fear of Making Mistakes/Errors
Dror I. … All errors need to be represented—slips, errors, mistakes.
Dror I.
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-insertion/licensed-staff/licensed-catheter.pptx
March 01, 2017 - an indwelling urinary catheter, using aseptic technique, let’s go over some things to avoid common mistakes
-
www.qualitymeasures.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncil2.html
April 01, 2018 - There is a new wave of consumers who have heard stories of or actually experienced errors, mistakes,
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
May 01, 2017 - These conditions are
the mistakes that occur without human error. … Sensemaking is a way for a L&D unit to learn
from and prevent mistakes.
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module6/ebmutualsupp.pdf
January 01, 2013 - e.g.,
inexperienced, incapable, overburdened, about to make an error), helping others correct their
mistakes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module6/ts2-0ltc_module6_support_evbase.pdf
January 01, 2013 - e.g.,
inexperienced, incapable, overburdened, about to make an error), helping others correct their
mistakes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-care/cathetercare-maintenance.pptx
March 01, 2017 - Cautioning team members about potentially unsafe situations
Self-correcting and helping others correct their mistakes … Cautioning team members about potentially unsafe situations
Self-correcting and helping others correct their mistakes