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161. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part I: Main Report (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt1-transition-updated.pdf
     June 01, 2022 - Shifting to a “Just Culture” framework to assess Response to Error; 4. … Survey Items Communication Openness Communication Openness 3 4 Feedback and Communication About Error … Communication About Error 3 3 Frequency of Events Reported Reporting Patient Safety Events 3 2 Handoffs … Support for Patient Safety Hospital Management Support for Patient Safety 3 3 Nonpunitive Response to Error … Response to Error 3 4 Organizational Learning – Continuous Improvement Organizational Learning—

162. Previous Announcements About SOPS Surveys | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/sops/news/previous-announcements.html
     November 01, 2023 - Shifting to a “Just Culture” framework to assess  Response to Error. … Conducting research to assist in identifying processes and sources of error in diagnosis.

163. 2018 National Healthcare Quality and Disparities Report: Appendix A (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa1.pdf
     January 01, 2018 - or worsening, 2000 through 2016 or 2017 Improving Average Annual Percent Change Standard Error … -1.02 0.0 0.00 MEPS 15 (2002-2016) Not Changing Average Annual Percent Change Standard Error … Healthcare Quality and Disparities Report Not Changing Average Annual Percent Change Standard Error … months -0.62 0.0 MEPS 15 (2002-2016) Worsening Average Annual Percent Change Standard Error

164. Issue Brief 9: Improved Diagnostic Accuracy Through Probability-Based Diagnosis (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-probabilistic-thinking.pdf
     September 01, 2022 - Diagnostic error in clinical medicine exists in part because of the inherent uncertainty that stems … framework illustrates how future clinicians can be equipped to make more accurate diagnoses and reduce error … Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; … Diagnostic error in internal medicine.

165. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
     September 01, 2016 - How PSOs Help Health Care Organizations Improve Patient Safety Culture How PSOs Help Health Care Organizations Improve Patient Safety Culture Developing a culture of safety is an essential task for health care organizations as they strive to eliminate the factors that contribute to medical errors, patient harm, …

166. Hospital SOPS Translation Information | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/sops/international/hospital/translators.html
     October 01, 2014 - Feedback & Communication About Error (Never, Rarely, Sometimes, Most of the time, Always) C1.

167. New Challenge Competition Launched To Update and Re-Create TeamSTEPPS Videos | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/news/newsletters/e-newsletter/813.html
     May 01, 2022 - In another article  (PDF, 990 KB), researchers explored how an accepted definition of diagnostic error … They concluded that NASEM created a common understanding of diagnostic error that includes accuracy,

168. About the Toolkit Development | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.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 …

169. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
     May 01, 2016 - although there was some overlap in activities: (1) improving communication by assessing attitudes toward error … “Common human error” and “not taking time to do the task correctly” were the two most commonly identified … Including nurses and other clinical staff in the formal root cause analysis (a common error analysis … Center complaint files from 2010 (including claims and lawsuits) in which patients reported clinical error … “Common human error” and “not taking time to do the task correctly” were the two most commonly identified

170. Ldusafety Facguide (doc file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
     May 01, 2017 - AHRQ Safety Program for Perinatal Care Labor and Delivery Unit Safety Labor and Delivery Unit Safety SAY: The “Labor and Delivery Unit Safety” bundle provides information on the key safety elements concerning four specific situations encountered in labor and delivery, and the importance of a comprehensive unit-based …

171. Preparing Data from CAHPS Surveys for Analysis (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/helpful-resources/analysis/preparing-data-for-analysis.pdf
     May 15, 2017 - critical if someone wants to go back later and conduct other analyses or tests, such as extent of error … response options, review the questionnaire and revise the data: • If the value was due to a data entry error

172. Enhancing Safety for Patients with Limited English Proficiency Train-the-Trainer Instructor Guide
     monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/traintrainers/lepigstafftrain.pptx
     November 19, 2008 - examples in which limited English proficiency and cultural misunderstandings led to a tragic medical error … Imagine how you would feel if you made an error in interpretation that caused your family member to become … Leaders also recognize that all humans can make mistakes and they ask for mutual support to avoid error

173. Cinco recomendaciones para recibir una mejor atención médica | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patients-consumers/care-planning/errors/5steps/cincorecsp.html
     September 01, 2014 - 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 …

174. TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/teamattitude.pdf
     March 21, 2014 - TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) TeamSTEPPS 2.0 TeamSTEPPS Teamwork Attitudes Questionnaire – F-9 TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) Instructions: Please respond to the questions below by placing a check mark (√) in the box that corresponds to your level of ag…

175. TeamSTEPPS Fundamentals Course: Module 5. Situation Monitoring | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/teamstepps/instructor/fundamentals/module5/igsitmonitor.html
     March 01, 2019 - Health care providers are just as prone to human error as the general population. … actions of fellow team members—or cross-monitoring—is a safety mechanism that can be used to mitigate error … Pham prevents a possible medication error. … Detected and corrected an error.

176. AHRQ-Funded Patient Safety Research Featured in Health Affairs | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patient-safety/reports/healthaffairs.html
     March 01, 2019 - 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 …

177. Hospitals and Health Systems | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patient-safety/settings/hospital/resource/index.html
     August 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 …

178. Selected Best Practices and Suggestions for Improvement (pdf file)
     monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
     May 20, 2016 - are factors that can be addressed by hospitals, such as nutritional status and decreasing surgical error … o Procedure related:  Emergency surgery  Types of surgery (clean vs. contaminated)  Surgical error

179. Yale Center for Healthcare Innovation, Redesign, and Learning | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/patient-safety/resources/learning-lab/yale-center-long-desc.html
     June 01, 2020 - 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 …

180. Learn about CUSP | Agency for Healthcare Research and Quality
     monahrq.ahrq.gov/hai/cusp/modules/learn/index.html
     July 01, 2018 - 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 …