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  1. monahrq.ahrq.gov/hai/cauti-tools/archived-webinars/leveraging-cultural-change-slides.html
    December 01, 2017 - expectations, (4) teamwork processes (e.g., back-up behavior), (5) resource allocation practices, and (6) error-detection … learning-continuous improvement Teamwork within unit Communication openness Feedback and communication about error … Nonpunitive response to error Staffing Hospital management support for patient safety Teamwork
  2. monahrq.ahrq.gov/news/newsletters/e-newsletter/index.html
    April 30, 2024 - 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 …
  3. monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
    August 01, 2022 - An adverse event is "any injury caused by medical care" and doesn't imply "error," "negligence," or poor
  4. monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps-webinar-071217.pptx
    January 01, 2017 - Introduction to the Fundamentals of TeamSTEPPS Concepts and Tools (Part 1 of 3) Introduction to the Fundamentals of TeamSTEPPS Concepts and Tools (Part 1 of 3) Wednesday, July 12, 2017 TEAMSTEPPS 05.2 Slide ‹#› Introduction to the Fundamentals of TeamSTEPPS Concepts and Tools (Part 1 of 3) Wednesday, July 12,…
  5. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_tools.docx
    January 01, 2012 - Short Portable Mental Status Questionnaire Question Response Error? … *A mistake on ANY part of this question should be scored as an error. … One less error is allowed if the patient has had education beyond the high school level. … Short Portable Mental Status Questionnaire Question Response Error? … * A mistake on ANY part of this question should be scored as an error.
  6. monahrq.ahrq.gov/research/findings/factsheets/index.html
    February 01, 2024 - 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 …
  7. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module8/igchangemgmt.pdf
    February 25, 2014 - TeamSTEPPS, Module 8: Change Management (Instructor Guide) CHANGE MANAGEMENT: HOW TO ACHIEVE A CULTURE OF SAFETY SUBSECTIONS • Eight Steps of Change • Errors Common in Organizational Change • Culture Change Comes Last, Not First • Change Strategies • Roadmap to a Culture of Safety TIME: 60 minutes …
  8. monahrq.ahrq.gov/patient-safety/settings/ambulatory/index.html
    July 01, 2022 - 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 …
  9. monahrq.ahrq.gov/news/psnet.html
    May 01, 2024 - publications, books, and tools related to patient safety, features a new set of articles including: Diagnostic error
  10. monahrq.ahrq.gov/news/newsletters/e-newsletter/881.html
    September 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 …
  11. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-slides-508.pdf
    April 10, 2018 - visits involve medicines 3.2 billion ordered or prescribed 160 million of those result in error … Studies show that 5 to 7 percent of those prescriptions result in error.
  12. monahrq.ahrq.gov/research/findings/final-reports/index.html?page=7
    December 01, 2007 - 7 8 9 next › ›› last » Last » Medication Error … Human Factors Approaches To Improve Patient Safety Publication Date: December 2006 Medication Error
  13. monahrq.ahrq.gov/hai/tools/ambulatory-care/safe-transitions.html
    December 01, 2017 - 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 …
  14. monahrq.ahrq.gov/cpi/about/35th-anniversary/index.html
    April 01, 2024 - Quality & Safety , was the largest of its kind at the time to address the frequency of diagnostic error … It concluded that an estimated 12 million U.S. adults will experience an outpatient diagnostic error … AHRQ continues to invest in research to produce tools and resources that help reduce diagnostic error
  15. monahrq.ahrq.gov/hai/cusp/toolkit/shadowing.html
    December 01, 2012 - Did you observe any error in transcription of orders by the provider you shadowed?       4. … Did you observe any error in the interpretation or delivery of an order?       5.
  16. monahrq.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
    March 01, 2019 - these data illustrate, failure to communicate effectively as a team significantly increases the risk of error … you describe an example in which a communication breakdown was the major contributing factor of an error … To avoid making assumptions that can lead to error, you should verify in writing or orally any nonverbal … about who is responsible for care and decisionmaking has often been a major contributor to medical error
  17. monahrq.ahrq.gov/hai/pfp/haccost2017.html
    November 01, 2017 - parameters, we extracted available information to calculate additional cost estimates and standard error … cost is the adjusted mean difference between cases and non-cases Standard deviation (SD) Standard error … Reason for effect size variation Variation comes from random error within studies and true variation … Variation comes from random error within studies. … studies that only reported attributable cost and significance level because we cannot generate a standard error
  18. monahrq.ahrq.gov/teamstepps-program/resources/additional/check-back-team.html
    July 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 …
  19. monahrq.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
    June 01, 2022 - 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 …
  20. monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
    May 01, 2023 - Staff can use this decision tree when analyzing an error or adverse event in an organization to help … The goals of this manual are to: • Raise awareness of error-prone processes in the medication delivery

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