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Showing results for "mistakes".

3081. Session 1 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
      October 01, 2014 - Module 3: Falls Prevention and Management Session 1 Previous Page Next Page Table of Contents Module 3: Falls Prevention and Management Learning and Performance Objectives Session 1 Session 2 Conclusion Appendix. Additional Tools and Resources Introduction Case Study: Mr.…

3082. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49794/psn-pdf
      May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…

3083. What Makes a Good Checklist | PSNet
      psnet.ahrq.gov/perspective/what-makes-good-checklist
      October 01, 2010 - repeated surgical errors in some hospitals.( 5 ) Checklists, however, are not a panacea for medical mistakes

3084. In Conversation with...Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
      October 01, 2010 - repeated surgical errors in some hospitals.( 5 ) Checklists, however, are not a panacea for medical mistakes

3085. Primary Care and Patient Safety: Opportunities at the Interface | PSNet
      psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
      September 28, 2022 - decreasing the time spent with patients and potentially increasing likelihood of errors, lapses, and mistakes … people hear “medical errors” and you’re going to point a finger at me or accuse me of making medical mistakes … The bulk of serious medical mistakes probably occur in acute settings where major decisions have to be … of primary care practices, and we asked them to think about patient safety, near misses, and medical mistakes … We had I think well over 1,000 submissions in a year or so about patient safety, patient medical mistakes

3086. In response to “Getting to the Root of the Matter” (June 2005) | PSNet
      psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
      June 01, 2005 - In response to “Getting to the Root of the Matter” (June 2005) September 1, 2005  View more articles from the same authors. Citation Text: Grondin L, Saint S, Flanders S, et al. In response to “Getting to the Root of the Matter” (June 2005). PSNet [internet]. Rockv…

3087. (“Apply CUSP” cover slide with CUSP Toolkit logo)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/applycusp.pptx
      August 18, 2011 - (“Apply CUSP” cover slide with CUSP Toolkit logo) 1 Learning Objectives Review key steps of the CUSP Toolkit Learn how Just Culture principles can augment CUSP 2 Introduce Just Culture principles 2 Introduction to Just Culture Principles 3 3 Understand Just Culture 4 4 Just Culture1 A system t…

3088. Timing Promotion of a Quality Report for Maximum Impact | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/distribute/promote/timing.html
      March 01, 2016 - Timing Promotion of a Quality Report for Maximum Impact As part of the initial planning of your promotional campaign, one critical consideration is the timing of your activities. Most health care decisions that can be influenced by comparative quality reports happen for different people at different times. …

3089. Urinary Catheter Types and How To Care for Them Activity | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-insertion/unlicensed-staff/scenarios-instr.html
      March 01, 2017 - Urinary Catheter Types and How To Care for Them Activity AHRQ Safety Program for Long-Term Care: HAIs/CAUTI Staff Role Play—How good are your catheter care skills? Roleplaying can be a helpful training and educational tool. Roleplaying allows staff to actively practice the skills they are learni…

3090. Improving Patient Safety in Nursing Homes: A Resource List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-resource-list-2.0.pdf
      April 01, 2025 - • Teamwork • Staffing • Organizational Learning • Handoffs and Information Exchange • Response to Mistakes … .................................................................................... 4 Response to Mistakes … Response to Mistakes 1. … Resources by Composite Measure Teamwork Staffing Organizational Learning Response to Mistakes

3091. Final Progress Report: Ambulatory Patient Safety of Clients in Treatment for Substance Abuse (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/mcfarland-report.pdf
      January 01, 2025 - With the exception of reporting mistakes to risk management personnel, staff members indicated they … Interestingly, an almost opposite pattern emerged for reporting mistakes to risk managers.

3092. Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
      March 01, 2016 - Response to Mistakes .................................................... 9 Composite 8. … Response to Mistakes 1. … Response to Mistakes Composite 8.

3093. Final Progress Report:: The National Quality Forum – Annual Meeting 2003 (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/kizer-report.pdf
      January 01, 2024 - Lunch Speaker: Rosemary Gibson, Author, “Wall of Silence: The Untold Story of the Medical Mistakes … That Kill and Injure Millions of Americans” Health consultant Gibson described how medical mistakes … LUNCH Rosemary Gibson, Author, “Wall of Silence: The Untold Story of the Medical Mistakes That Kill

3094. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
      January 01, 2002 - Medical Errors Climate, Stress, and Error in Primary Care 67 likelihood that they would commit mistakes … possible, as Firth-Cozens suggests,1 that stressed physicians are more likely to presume they will make mistakes … The tendency to make mistakes was associated with a lack of emphasis on quality, information, and communication

3095. On-line Patient Safety Climate Survey: Tool Development and Lessons Learned (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Connelly.pdf
      January 01, 2003 - went wrong when a sentinel event occurs. 3.10 .611 Agree 13. often blame others for their own mistakes … They further agreed with the statement, “Most people in this MTF often blame others for their own mistakes … willing to discuss what went wrong when a sentinel event occurs. 13. often blame others for their own mistakes

3096. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - There are two objectives of safe system design: (i) to make it difficult for individuals to make mistakes … Such strategies are unlikely to prevent an error from occurring again as they rely on humans to avoid mistakes

3097. Ldusafety Facguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
      May 01, 2017 - Errors associated with failures of attentional behavior are labeled “mistakes” and often occur because … Most errors in health care are slips rather than mistakes.

3098. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49792/psn-pdf
      May 01, 2017 - Mistakes were made. BMJ Emergency Medicine Journal Blog. December 17, 2015. [Available at] 23. … www.ncbi.nlm.nih.gov/pubmed/23218508 https://www.ncbi.nlm.nih.gov/pubmed/14634609 http://blogs.bmj.com/emj/2015/12/17/mistakes-were-made

3099. Strategies for Improving Patient Experience with Ambulatory Care: Service Recovery Programs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/cahps-strategy-6-p.pdf
      November 02, 2017 - Axiom 4: Customers react more strongly to “fairness mistakes” than “honest mistakes.”

3100. Mutual Support: Obstetric Hemorrhage - PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_5-mutual-support.pptx
      July 01, 2023 - Often we are already aware of our limitations, shortcomings, and mistakes. … People can feel targeted and embarrassed when their mistakes are pointed out in public, and they may … Recognize that we are all trying to do the best we can and making mistakes is hard on us.