-
www.qualitymeasures.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.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-survey.pdf
June 06, 2018 - Such prevention
includes reducing mistakes, errors, incidents, events, or problems that lead to patient … effective team ...................... 1 2 3 4 5 9
SECTION C: Organizational Learning/Response to Mistakes … 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 ................................. … in This Facility
SECTION B: Teamwork and Training
SECTION C: Organizational Learning/Response to Mistakes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/sops-nurse-home-items-06-16-21.pdf
January 01, 2000 - Nonpunitive Response to Mistakes
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly … Staff are afraid to report their mistakes. (negatively worded)
A15. … Staff are treated fairly when they make mistakes.
A18. … Staff feel safe reporting their mistakes. … This nursing home lets the same mistakes happen again and again. (negatively worded)
D4.
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www.qualitymeasures.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.qualitymeasures.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.qualitymeasures.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.qualitymeasures.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.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool1a.docx
January 01, 2004 - 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. … 4
5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the following mistakes
-
www.qualitymeasures.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.qualitymeasures.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.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-survey.docx
June 06, 2018 - Such prevention includes reducing mistakes, errors, incidents, events, or problems that lead to patient … team ......................
1
2
3
4
5
9
SECTION C: Organizational Learning/Response to Mistakes … 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 ...................................
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
May 31, 2023 - Blaming the people who made mistakes.
e. Attending the autopsy.
11. … Leaders not make mistakes.
e. Everyone agrees with the plan. … Focus on the safety, not the error
• A debrief would be good, but not to have the nurse “explain her mistakes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/ambulatory-surgery-sops-items-and-composites.pdf
January 01, 2015 - Response to Mistakes
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree … Staff are treated fairly when they make mistakes.
C4. … Learning, rather than blame, is emphasized when mistakes are made.
C5.
-
www.qualitymeasures.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.qualitymeasures.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.qualitymeasures.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.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/learnbench.pdf
February 28, 2014 - Blaming the people who made mistakes.
e. Attending the autopsy.
11. … Leaders not make mistakes.
e. Everyone agree with the plan. … on the safety, not the error
• A debrief would be good, but not to have
the nurse “explain her mistakes
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/medical-office-survey-english.pdf
March 01, 2023 - Staff feel like their mistakes are held against
them............................................... … Staff are willing to report mistakes they observe
in this office .................................. … They overlook patient care mistakes that
happen over and over ................................ … Our office processes are good at
preventing mistakes that could affect
patients .................. … It is just by chance that we don’t make
more mistakes that affect our patients .......
-
www.qualitymeasures.ahrq.gov/teamstepps/instructor/reference/learnbench.html
March 01, 2014 - Blaming the people who made mistakes.
Attending the autopsy. … Leaders not make mistakes.
Everyone will agree with the plan. … Focus on the safety, not the error
A debrief would be good, but not to have the nurse "explain her mistakes
-
www.qualitymeasures.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.