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Showing results for "mistakes".

  1. Presentation Slides | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/modules/apply/sl-cusp.html
    December 01, 2012 - Presentation Slides CUSP Toolkit, Apply CUSP The Apply CUSP module of the CUSP Toolkit introduces Just Culture principles, which emphasize shared accountability and attitudes towards risk. This module also summarizes the concepts and activities of the other six modules in the CUSP Toolkit, including TeamSTEPP…

  2. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
    March 01, 2015 - PowerPoint Presentation Spotlight Two Wrongs Don't Make a Right (Kidney) This presentation is based on the March 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John G. DeVine, MD, Professor of Orthopaedic Surgery, Medical College of Georgia Ed…

  3. Utilization of ISO 9001 Principles as a Model for Community Cooperation in Establishing an Anticoagulation Clinic (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/2006Levett_051711comp.pdf
    June 16, 2021 - Utilization of ISO 9001 Principles as a Model for Community Cooperation in Establishing an Anticoagulation Clinic Kirkwood Community College Lead Organization James M. Levett, M.D. Principal Investigator Physicians’ Clinic of Iowa Cedar Rapids, Iowa Utilization of ISO 9001 Principles as a Model for Community Coope…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33588/psn-pdf
    March 15, 2025 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events March 15, 2025 Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events PSNet primers are regu…

  5. In Conversation With… Linda Aiken, PhD, RN | PSNet

    psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
    March 01, 2018 - A majority of nurses say that they and other staff feel like their mistakes are held against them and … Improving patient safety requires us not just to reduce the risk of mistakes being made, but also to

  6. Sensemakingnotes (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/identify/sensemakingnotes.docx
    June 02, 2025 - These conditions are the mistakes that occur without human error. … Sensemaking is a way for a unit to learn from and prevent mistakes.

  7. Labor and Delivery Unit Safety (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.pdf
    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.

  8. In Conversation with… Michael Cohen, RPh, MS, ScD (hon) | PSNet

    psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
    April 01, 2006 - Doctors, obviously, may still make mistakes; even if they get warnings, mistakes can get through.

  9. Missed Nursing Care: A Key Measure for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
    March 01, 2018 - Improving patient safety requires us not just to reduce the risk of mistakes being made, but also to … A majority of nurses say that they and other staff feel like their mistakes are held against them and

  10. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet

    psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
    October 02, 2013 - cognitive factors may predispose to misdiagnosis ( 10 ), diagnostic errors are most often linked to bedside mistakes … Do house officers learn from their mistakes? Qual Saf Health Care. 2003;12:221-226.

  11. National Web-Based Teleconference on Health IT and Safety - Using Health IT to Prevent Adverse Events (pdf file)

    digital.ahrq.gov/sites/default/files/docs/Health_IT_and_Safety_070910_comp.pdf
    July 13, 2010 - National Web-Based Teleconference on Health IT and Safety - Using Health IT to Prevent Adverse Events National Web-Based Teleconference on Health IT and Safety Using Health IT to Prevent Adverse Events July 13, 2010 Moderator: Amy Helwig Agency for Healthcare Research and Quality Presente…

  12. From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
    January 01, 2004 - From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings 381 From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings Ann Freeman Cook, Helena Hoas, Katarina Guttmannova Abstract To date, few studies have focused on pat…

  13. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
    January 01, 2024 - Their stated aim was “to help save lives and reduce preventable medical mistakes by mobilizing employer … efforts on three principles that would have a high impact on saving lives by reducing preventable mistakes

  14. Discharged Blindly | PSNet

    psnet.ahrq.gov/web-mm/discharged-blindly
    October 26, 2022 - December 14, 2022 The source of purchased medications and its impact on medication mistakes

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33773/psn-pdf
    September 01, 2014 - diagnoses or additional treatments, which in turn creates "more to do" and ultimately can lead to mistakes

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866621/psn-pdf
    August 28, 2024 - examine processes from the perspective of those involved to grasp the intricacies and risks of potential mistakes

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33778/psn-pdf
    March 01, 2015 - in order to be able to create measures that will https://psnet.ahrq.gov/issue/why-do-doctors-make-mistakes-study-role-salient-distracting-clinical-features

  18. Info FAQs | Agency for Healthcare Research and Quality

    www.ahrq.gov/faqs/index.html?page=4
    June 12, 2025 - Nonpunitive response to mistakes. Organizational learning.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49467/psn-pdf
    December 01, 2004 - Many telephone mistakes occur as a result of inadequate data available to the covering physician.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33623/psn-pdf
    December 01, 2005 - Without these vital conversations, there is no learning from mistakes and near misses, increasing the
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