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2021. Decision Support System Design and Implementation for Outpatient Prescribing: The Safety in Prescribing Study (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Feldstein.pdf
      January 01, 2004 - Of these studies, two demonstrated a marked decrease in the serious medication error rate, one showed … computer applications according to how easy they are to learn and remember, and their efficiency, error … The impact of computerized physician order entry on medication error prevention. … Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel

2022. Hospital Survey on Patient Safety Culture Version 2.0 Spanish (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-Spanish-05.18.21.docx
      June 09, 2016 - . · Un “evento de seguridad del paciente” se define como cualquier tipo de error, equivocación, o incidente … Cuando se descubre un error y se corrige antes de que afecte al paciente, ¿con qué frecuencia se reporta … Cuando un error afecta al paciente y pudo haberle causado daño, pero no fue así, ¿con qué frecuencia

2023. Programa de seguridad de la AHRQ para cuidados a largo plazo: HAI/CAUTI Kit de herramientas de seguridad para cuidados a largo plazo:
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module1/safetymodule-slides-spanish.pptx
      April 21, 2014 - cusptoolkit/videos/07a_just_culture/index.html 17 Comprender el riesgo y el comportamiento humano1 Error … humano: Cometer sin querer un desacierto: una equivocación, un descuido, un error Comportamiento de … cuidados a largo plazo Aplicar principios de seguridad | ‹#› 18 Manejar los errores y los riesgos1 Error

2024. TeamSTEPPS for Patients and Patient Engagement
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-march2013.pptx
      January 01, 2013 - capacity Patient Engagement Webinar TEAMSTEPPS 05.2 Mod 1 05.2 Page ‹#› TeamSTEPPS Facing Medical Error … Surgical Error: “Wet Run” and an apology Ripple Effect of Reactions: In the OR In the Transplant … #› TeamSTEPPS The Role of Patients in Patient Safety Most patient safety strategies are focused on error

2025. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles | Agency for Healthcare Research and Quality
      ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-slides.html
      March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1 Human Error: Inadvertently completing the wrong … Slide 19: Managing Error and Risk 1 Human Error At-Risk Behavior Reckless Behavior

2026. Improving Your Laboratory Testing Process Toolkit (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
      December 01, 2017 - primary care offices consistently show that the process for managing tests is a significant source of error … Some of the tools can help you identify error-prone aspects of your lab testing process, and others … Any of these steps can be a source of error if the office system allows it. … each step. • Circle the number that you feel most accurately describes the harm associated with the error … Design a change to reduce error in your office system by using a Planning for Improvements tool.

2027. Presentation: Program Overview
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-slides.pptx
      January 01, 2017 - A B L A N C A A B A D B A D D A Y Patient squeezes the provider’s hand when he hears the letter “A” Error … present if the patient commits more than two errors If the patient squeezes on every letter, assign an error … count of 10 If the patient doesn’t squeeze on any letter, assign an error count of 10 Early Mobility

2028. Catheter Care and Maintenance Quiz | Agency for Healthcare Research and Quality
      ce.effectivehealthcare.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/quiz.html
      March 01, 2017 - Determine the catheter care error. … Determine the catheter care error.

2029. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
      July 01, 2004 - explicit review is a patient-centered process focusing on patient harm rather than provider or system error … As opposed to a provider-centered focus of error elimination, fault tolerance attempts to create systems … , our design assumes that the leverage point for improvement interventions is fault tolerance, not error … To that end, we have no measures of individual provider performance or provider error. … of our nation’s health care delivery systems reaches beyond the limitations of identifying provider error

2030. TeamSTEPPS 2.0 Module 1: Introduction
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule1.pptx
      January 01, 2011 - These errors can occur for many reasons, and a single error can often be linked to a number of causal … on evidence derived from teams working in high-risk environments, those areas where consequences of error … provide specific tools and strategies for improving communication and teamwork, reducing chance of error

2031. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
      January 01, 2003 - are based did not have access to actual insurance claims data for patients who experienced a medical error … Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel

2032. Spanish Medical Office Survey on Patient Safety Culture Items and Dimensions (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/resources/modim_sp.pdf
      December 01, 2011 - Spanish Medical Office Survey on Patient Safety Culture Items and Dimensions D-1 Spanish Translation of AHRQ’s Medical Office Survey on Patient Safety December 2011 This document explains the process that was used to develop a Spanish translation of the Agency for Healthcare Research and Quality (AHRQ) Medica…

2033. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-facguide.docx
      January 01, 2017 - Finally, error-detection and correction systems are used to report medical errors and any other errors … postoperative hemorrhage, respiratory failure, accidental puncture or laceration, and fewer treatment error … Having open communication involves having a discussion and receiving feedback about error, nonpunitive … response to error, staffing, hospital management support for patient safety, and teamwork across hospital

2034. FileNewTemplate
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module9.pptx
      March 07, 2019 - FileNewTemplate Module 9: Change Management Office-Based Care Online Course Welcome to the Welcome to the TeamSTEPPS for Office-Based Care Online Course. This is Dr. Brigetta Craft. This presentation will cover Module 9, Change Management, that you, as a practice facilitator, will review. 1 The Materials You …

2035. The Role of Patient Safety in the Device Purchasing Process (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Johnson.pdf
      January 01, 2004 - Facility Reporting, that addresses usability issues from time to time; device alerts that include usage error … the medical devices most commonly used in hospitals, and they are well represented in medical device error … Section 7 surveyed the subject’s attitudes toward errors and error prevention. … It involved a medical error scenario and several followup questions regarding factors that may have … contributed to the error and actions that might be taken to prevent a recurrence.

2036. Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Davis.pdf
      February 12, 2004 - Authorization Act of Fiscal Year 2001(NDAA 01), sections 742 and 754, established a centralized patient care error … reporting systems similar to the Veteran Health Administration (VHA) Patient Safety Reporting Program for error … Since no comparable national medical error incident reporting system was in place, a new system needed … The PSWG defines a near miss as: “any process variation or error that could have resulted in harm to … The system has helped to identify patterns of error and areas that need to be addressed in the forthcoming

2037. TeamSTEPPS 2.0 Module 8: Change Management
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule8.pptx
      March 28, 2006 - TeamSTEPPS 2.0 Module 8: Change Management Module 8: Change Management Online Master Trainer Course Welcome to the Welcome to module eight of the TeamSTEPPS 2.0 online master trainer course, Change Management: How to Achieve a Culture of Safety. This is Dr. Brigetta Craft, and I'll be guiding you through thi…

2038. An Overview of the CANDOR Process
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
      September 10, 2015 - well as information on Event Investigation and Analysis. 3 “The single greatest impediment to error … testimony before Congress on health care quality improvement that “The single greatest impediment to error … system processes and factors that facilitated the event, adjustments can be made to minimize human error

2039. Presentation: Science of Improving Patient Safety and Identifying Defects
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
      December 01, 2017 - not want to happen again—an unsafe condition, a patient fall, a venous thromboembolism, a medication error

2040. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
      March 23, 2008 - The Institute of Medicine (IOM) definitions of medical error and adverse event were adapted for study … A medical error was defined as “the failure to complete a planned action as intended or the use of a … An adverse event was defined as “an injury caused by medical management error rather than the patient … Emergency medicine: A practice prone to error? Can J Emerg Med 2001; 3: 271-276. 15. … Promoting patient safety and preventing medical error in emergency departments.