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psnet.ahrq.gov/issue/rural-community-members-perceptions-harm-medical-mistakes-high-plains-research-network-hprn
February 03, 2011 - Study
Rural community members' perceptions of harm from medical mistakes: a High … Rural community members' perceptions of harm from medical mistakes: a High Plains Research Network (HPRN … Rural community members' perceptions of harm from medical mistakes: a High Plains Research Network (HPRN
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psnet.ahrq.gov/issue/ethics-pediatric-emergency-department-when-mistakes-happen-approach-process-evaluation-and
December 13, 2013 - Review
Ethics in the pediatric emergency department: when mistakes happen: an approach … Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Evaluation … Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Evaluation
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psnet.ahrq.gov/issue/work-hour-rules-and-contributors-patient-care-mistakes-focus-group-study-internal-medicine
February 22, 2011 - Study
Work hour rules and contributors to patient care mistakes: a focus group study … Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine … Work hour rules and contributors to patient care mistakes: a focus group study with internal medicine
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psnet.ahrq.gov/node/44794/psn-pdf
May 21, 2019 - psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
Applying human factors engineering to examine mistakes … about utilizing root cause analysis (RCA) to identify weaknesses in device design that enable those
mistakes
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psnet.ahrq.gov/node/60633/psn-pdf
July 01, 2020 - health care organizations to assess how often
patients who read open ambulatory visit notes perceive mistakes … The most common very serious
mistakes involved incorrect diagnoses; medical history; allergy or medication
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www.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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-items.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. … Pace
4.Teamwork
5.Staff Training
6.Organizational Learning – Continuous Improvement
7.Response to Mistakes
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - To prevent unintentional unsafe acts—slips, lapses, mistakes, or procedure violations—the contributory … Because health care professionals often treat their mistakes as personal failures, I'd speculate that … How many other patients must be harmed by similar mistakes before the factors that led to the mistakes … It is impossible to determine the rate of unacknowledged medical mistakes, especially in the absence … openly.( 17 ) Where there was a climate of fear, willingness to report mistakes was reduced.
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psnet.ahrq.gov/issue/frequency-and-types-patient-reported-errors-electronic-health-record-ambulatory-care-notes
June 05, 2019 - care organizations to assess how often patients who read open ambulatory visit notes perceive mistakes … The most common very serious mistakes involved incorrect diagnoses; medical history; allergy or medication
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psnet.ahrq.gov/issue/digital-doctor-hope-hype-and-harm-dawn-medicines-computer-age
January 09, 2018 - dissatisfaction, changing relationships among providers and between providers and patients, new kinds of medical mistakes … , 2019
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes … October 3, 2017
Black Box Thinking: Why Most People Never Learn From Their Mistakes—But
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www.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
June 01, 2023 - Ensuring that mistakes or oversights are caught quickly and easily. … provide a safety net or an error prevention or error interruption mechanism for the team, ensuring that mistakes
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psnet.ahrq.gov/issue/learning-mistakes-factors-influence-how-students-and-residents-learn-medical-errors
November 15, 2011 - Study
Classic
Learning from mistakes: factors that influence … Learning from mistakes. … Learning from mistakes.
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psnet.ahrq.gov/issue/finding-and-fixing-mistakes-do-checklists-work-clinicians-different-levels-experience
February 06, 2014 - Study
Finding and fixing mistakes: do checklists work for clinicians with different … Finding and fixing mistakes: do checklists work for clinicians with different levels of experience? … Finding and fixing mistakes: do checklists work for clinicians with different levels of experience?
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psnet.ahrq.gov/issue/six-ways-lower-errors-and-unnecessary-surgeries-radiology-exams
February 10, 2021 - Discussing cognitive and system factors in radiology that contribute to diagnostic mistakes, this … Topic
Physicians
Information Professionals
Patients
Radiology
Cognitive Errors ("Mistakes
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/infotransNHSOPS.pdf
January 01, 2010 - Staff are afraid to report their mistakes. (negatively worded)
A15. … Staff are treated fairly when they make mistakes. … Staff feel safe reporting their mistakes. … Feedback & Communication About Incidents (More about this dimension: Typical
errors/mistakes/incidents … This nursing home lets the same mistakes happen again and again. (negatively worded)
D4.
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psnet.ahrq.gov/issue/no-one-listening-us
July 01, 2020 - Stressful working conditions are known to increase the potential for medical mistakes. … May 5, 2021
5 pandemic mistakes we keep repeating.
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psnet.ahrq.gov/node/47861/psn-pdf
April 24, 2019 - /psnet.ahrq.gov/issue/diagnostic-delays-paediatric-stroke
https://psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it … https://psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
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psnet.ahrq.gov/node/852456/psn-pdf
August 16, 2023 - psnet.ahrq.gov/issue/residents-responsibility-and-error-how-residents-learn-navigate-intersection
Learning from mistakes … learning-errors-and-resilience
https://psnet.ahrq.gov/issue/learning-errors-and-resilience
https://psnet.ahrq.gov/issue/learning-mistakes-factors-influence-how-students-and-residents-learn-medical-errors
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psnet.ahrq.gov/issue/new-york-city-puts-hospital-error-data-online
January 23, 2019 - September 19, 2018
Report 6: Managing Risk and Minimising Mistakes in Services to Children … October 3, 2017
Hidden mistakes in hospitals. … October 3, 2017
More families hear apologies following medical mistakes.
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psnet.ahrq.gov/issue/are-patients-part-blame-when-doctors-miss-diagnosis
May 01, 2013 - April 15, 2009
When doctors admit their mistakes. … September 16, 2009
When doctors make mistakes. … June 9, 2010
Take Charge of Your Hospital Stay to Avoid Medical Mistakes.