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www.talkingquality.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
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www.talkingquality.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/finalsummary/finalsummary6.html
September 01, 2015 - Apply lessons learned from each other to avoid repeating mistakes and improve the quality of their projects
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www.talkingquality.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
March 01, 2024 - patient-reported diagnostic process-related breakdowns” framework can help organizations learn from mistakes
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www.talkingquality.ahrq.gov/talkingquality/resources/design/testing.html
September 01, 2019 - showed that college-educated people with strong quantitative and analytical experience made numerous mistakes
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www.talkingquality.ahrq.gov/news/blog/ahrqviews/addressing-historical-racism.html
April 01, 2021 - We understand that we may make mistakes.
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www.talkingquality.ahrq.gov/teamstepps/instructor/reference/teamattitude.html
April 01, 2017 - Effective leaders view honest mistakes as meaningful learning opportunities.
10
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www.talkingquality.ahrq.gov/teamstepps/officebasedcare/handouts/teamattitudes.html
December 01, 2015 - Effective leaders view honest mistakes as meaningful learning opportunities.
10
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www.talkingquality.ahrq.gov/teamstepps/officebasedcare/module7/office_summary.html
February 01, 2016 - Ensuring mistakes/oversights are caught.
STEP checklist:
Status of the patient.
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
May 01, 2017 - humans, and humans are fallible
Medicine is still treated as an art, not a science
Systems do not catch mistakes
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module1.pptx
March 01, 2010 - 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.talkingquality.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/member-codebook-6mon-post-intervention.pdf
January 01, 2014 - the following statements about your practice (select only one response):
AR11, 2
FOA Required
Mistakes … Practice Member Survey Code Book
AR10
FOA Required
This practice learns from its mistakes
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www.talkingquality.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
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www.talkingquality.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
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www.talkingquality.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."
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www.talkingquality.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
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www.talkingquality.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.
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www.talkingquality.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
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www.talkingquality.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
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www.talkingquality.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,
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www.talkingquality.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.