-
psnet.ahrq.gov/node/39276/psn-pdf
March 09, 2011 - series on medical radiation, this news feature investigates patient deaths and injuries following
mistakes … radiation therapy errors in
New York and reveal that state law does not require public reporting of such mistakes
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psnet.ahrq.gov/issue/patient-and-family-engagement-incident-investigations-exploring-hospital-manager-and-incident
November 04, 2020 - December 18, 2014
U.S. to delete data on life-threatening mistakes from website. … February 3, 2011
Learning from mistakes in New Zealand hospitals: what else do we need … October 7, 2008
Coming clean on medical mistakes.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/opennotes-a.pdf
April 01, 2016 - .
■ Catch mistakes or misunderstandings.
■ Remember to get any followup tests. … When patients, families, doctors, and staff work
as partners, they prevent mistakes and get better results
-
www.ahrq.gov/sops/international/nursing-home/translators.html
October 01, 2014 - Nonpunitive Response to Mistakes
( More about this dimension: In a nonpunitive environment, when a … Staff are afraid to report their mistakes. (negatively worded)
A15. … Staff are treated fairly when they make mistakes. ( More about this item: Staff expect supervisors to … consequences for them or that they will be punished unfairly if they report mistakes .)
6. … This nursing home lets the same mistakes happen again and again. (negatively worded)
D4.
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psnet.ahrq.gov/issue/antidote-medical-errors
May 02, 2017 - This feature article explains how cognitive errors contribute to medical mistakes and describes ways … Behaviorists
Patients
Diagnostic Errors
Psychological and Social Complications
Cognitive Errors ("Mistakes
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psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-trigger-dangers
June 29, 2016 - details errors involving medication name confusion and presents tips for consumers to avoid such mistakes … March 18, 2010
Catching deadly drug mistakes.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/hospital/2024-hospital-database-report-summary.pdf
January 01, 2024 - Measures
Response to Error 64%
of respondents reported that staff are
treated fairly when they make mistakes … and
there is a focus on learning from mistakes
and supporting staff involved in errors.
-
psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - Lack of predictability greatly
increases the risk of mistakes. … was the result of a complex system with multiple communication failures, which is how most
medical mistakes … Many things had to
go wrong for all these mistakes (ie, the "holes in the This error was the result … of a complex system with
multiple communication failures, which is how most medical mistakes happen. … Many things had to go wrong for all these mistakes (ie, the "holes in the
Swiss cheese") to line up.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/resources/infotransMOSOPS.pdf
January 01, 2010 - Staff feel like their mistakes are held against them. … Staff are willing to report mistakes they observe in this office.
10. … They overlook patient care mistakes that happen over and over. … Mistakes happen more than they should in this office. (negatively worded)
F4. … It is just by chance that we don’t make more mistakes that affect our patients.
-
www.ahrq.gov/sops/international/medical-office/translators.html
January 01, 2010 - Staff feel like their mistakes are held against them. … Staff are willing to report mistakes they observe in this office.
10. … They overlook patient care mistakes that happen over and over. … Mistakes happen more than they should in this office. (negatively worded)
F4. … It is just by chance that we don't make more mistakes that affect our patients.
-
psnet.ahrq.gov/node/46461/psn-pdf
November 01, 2017 - relationships can be developed to help address these
barriers and learn from outcomes associated with mistakes … psnet.ahrq.gov/issue/piece-my-mind-shame-guilt-love
https://psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes
-
psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture
May 02, 2018 - contributed to the failure, urges leadership to modify the use of blame tactics in response to medical mistakes
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/sops-hsops-2-translation-guidelines.pdf
August 01, 2023 - In this unit, staff feel like their mistakes are held against them. … (negatively worded)
• More about this item: Staff feel like they are unfairly blamed when mistakes … • More about this item: When staff make any errors or mistakes, supervisors/managers don’t
immediately
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
January 01, 2004 - Overall, providers perceived a variety of obstacles to revealing mistakes. … Do house
officers learn from their mistakes? JAMA
1991;265:2089–94.
8. … The heart of
darkness: the impact of perceived mistakes on
physicians. … Legal anxieties and medical mistakes:
barriers and pretexts. … Do health care managers have
an ethical duty to admit mistakes?
-
psnet.ahrq.gov/node/33653/psn-pdf
June 01, 2007 - In reply:
I appreciate that Vaida and Paparella have built on my commentary, which emphasized why mistakes … Failing to recognize mistakes contributes to organizational inertia and individual complacency. … To make health care safer, we need an understanding of what causes mistakes and good ideas on how to … Acknowledging and reporting mistakes create the needed catalyst for
this willingness.
Patrice L.
-
psnet.ahrq.gov/issue/near-injury-alters-procedures-virginia-mason
September 21, 2005 - hospital's patient-safety approach is designed to openly identify and evaluate incidents to prevent future mistakes … July 5, 2006
Hospitals to tear up bills for medical mistakes.
-
psnet.ahrq.gov/node/34659/psn-pdf
April 07, 2010 - Harvard Business School, outlines the eight stages of a successful change process,
as well as common mistakes … These mistakes include not establishing a
great enough sense of urgency, not creating a powerful enough
-
psnet.ahrq.gov/node/35656/psn-pdf
June 14, 2011 - network to illustrate the value of
finding systemic contributions to rare but potentially dangerous mistakes … normal-neurologic-and-developmental-outcome-after-accidental-intravenous-infusion-expressed
https://psnet.ahrq.gov/primer/root-cause-analysis
https://psnet.ahrq.gov//#mistakes
-
psnet.ahrq.gov/node/41392/psn-pdf
July 02, 2014 - The four types of errors classified were skill-based
slips and lapses, rule-based mistakes, knowledge-based … mistakes, and violations.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/composite-measures-english.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.