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21. Facilitator Notes | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
    December 01, 2012 - Managing Error and Risk Slide 8. Systems and Behaviors Work Together To Improve Outcomes Slide 9. … Can you identify examples of human error in your unit or hospital? … Managing Error and Risk   Say: To improve outcomes, human error, at-risk behavior, and reckless … Human error is a product of both system design and behavioral choices. … Describe the connections between communication and medical error.

22. Issue Brief 7. Improving Education: A Key to Better Diagnostic Outcomes (pdf file)
    healthcare411.ahrq.gov/sites/default/files/publications2/files/dxsafety-issuebrief-education.pdf
    March 11, 2022 - Diagnostic error in internal medicine. … Cognitive interventions to reduce diagnostic error: a narrative review. … Overconfidence as a cause of diagnostic error in medicine. … Clinical reasoning and diagnostic error: a call to merge two worlds. … Nurses, diagnosis, and diagnostic error.

23. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/diagnostic-safety/tools/index.html
    March 01, 2024 - primary care offices consistently show that the process for managing tests is a significant source of error … a checklist and other resources to help patients understand what they can to do prevent diagnostic error … Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error

24. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
    July 05, 2023 - Thus, capitation and payer integration lie to the left of direct error penalties in . … What is Diagnostic Error?: Improvediagnosis.org. diagnostic-error/ [Accessed 26 Jul 2022]. 6. … Payment innovations to improve diagnostic accuracy and reduce diagnostic error. … Interventions targeted at reducing diagnostic error: systematic review. … Diagnostic error inmedicine: analysis of 583 physician-reported errors.

25. Medical Errors and Patient Safety | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/research/findings/factsheets/errors-safety/index.html
    January 01, 2023 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

26. TeamSTEPPS Diagnosis Improvement Course | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/teamstepps-program/diagnosis-improvement/index.html
    February 01, 2024 - Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error … Helen Haskell, M.A., Mothers Against Medical Error.

27. Tool: Cross-Monitoring | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
    June 01, 2023 - Cross-monitoring is a harm and error reduction strategy that involves: Monitoring actions of other … Instead, it is a way to provide a safety net or an error prevention or error interruption mechanism for

28. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
    October 01, 2023 - Walsh received a 3-year AHRQ grant in 2015 to identify the factors that contribute to medication error

29. Diagnostic Safety Grants Awarded in FY 2019 | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/diagnostic-safety/research/grants-2019.html
    March 01, 2024 - machine learning models that can be used to retrospectively identify patients in whom a diagnostic error

30. Facapplycusp (doc file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
    September 04, 2012 - · Can you identify examples of human error in your unit or hospital? … Slide 6 SAY: To improve outcomes, human error, at-risk behavior, and reckless behavior each should … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console providers who have committed a human error and to ensure

31. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
    March 01, 2024 - Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating … 23 percent of patients treated at 29 academic medical centers in the U.S. experienced a diagnostic error … by Agency-funded research teams that have published essential insights into areas such as diagnostic error

32. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
    August 01, 2022 - occurring in 5 percent of ED visits translates to about 7 million cases of ED-based diagnostic error … What interventions could reduce diagnostic error in emergency departments? … inform diagnosis and error. … Interdisciplinary communication: an uncharted source of medical error? … Diagnostic error in medicine: analysis of 583 physician-reported errors.

33. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.html
    August 01, 2022 - Slide 9 Say: To improve outcomes, human error, at-risk behavior, and reckless behavior should … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console providers who have committed a human error and to ensure … Forcing functions, checks, and redundancies are some features of systems intended to minimize the risk of error

34. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
    April 02, 2020 - Reducing Diagnostic Error: Measurement Considerations. … The challenges in defining and measuring diagnostic error. … The incidence of diagnostic error in medicine. … Minimizing diagnostic error: the importance of follow-up and feedback. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

35. TeamSTEPPS Implementation: Strategies for Success
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-august2013.pptx
    January 01, 2013 - Improvement from 2007 to 2011 Communication / Openness + 1% + 6.7% +6.8% Feedback and Communication about Error … 11.30% +10.1% Hospital Management Support for Patient Safety + 3% + 8% +12.5% Non-punitive Response to Error … AHRQ Question Improvement Communication Openness 3.3% Feedback and Communication about Error … Hospital Handoffs & Transitions 8.0% Hospital Management Support.. 5.8% Nonpunitive Response to Error

36. Working Together to Tackle Our Most Pressing Safety Issues | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/news/blog/ahrqviews/patient-safety-stakeholders.html
    March 01, 2021 - Participants agreed that a third specific research priority is diagnostic error. … Diagnostic error harms too many and costs too much .   … require dedicated effort and investments in order to prevent the substantial harm we know diagnostic error

37. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/funding/grantee-profiles/grtprofile-bell.html
    March 01, 2022 - “AHRQ is helping to pioneer a novel 360-degree approach to diagnostic error prevention by bringing patients … process so there’s a corrective mechanism that’s possible before it leads to duplication, diagnostic error … Among patients who reported a diagnostic error, the most common contributing factor patients reported … AHRQ’s vision to take such a pioneering stance on tackling the complex issue of ambulatory diagnostic error

38. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - If the focus is on the process and the system factors that facilitated the error, the process can be … adjusted to minimize human error, resulting in fewer opportunities to err again. … (Table 1) Table 1: Behavior Classification Normal Error (Human Error) At-risk Behavior Reckless … If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … questions such as "Why was there human error?

39. Agency for Healthcare Research and Quality | Agency for Healthcare Research and Quality
    healthcare411.ahrq.gov/cpi/about/mission/ahrq-fy2015-conf-spending.html
    January 01, 2016 - Total Non-Feds on Travel:  0 Center for Quality Improvement and Patient Safety (CQUIPS) Diagnostic Error … and final of three annual conferences to be held as part of the large conference grant "Diagnostic Error … response to the AHRQ funding mechanism PAR09-257 and supports the AHRQ/CQUIPS program to reduce medical error

40. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
    healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/fed-IWG-dxsafety-Nov19mtg.pdf
    November 15, 2019 - • Grants To Enable Diagnostic Excellence (4 awarded) CDC • Literature review linking laboratory error … grants.nih.gov/grants/guide/rfa-files/RFA-HS-19-001.html https://www.ahrq.gov/patient-safety/diagnostic-error-grants