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61. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/teamstepps/instructor/scenarios/dental.html
    March 01, 2014 - brings to light the fact that this drug is an incorrect choice for a pregnant woman, the unfolding error … If the clinician had not recognized the error, the pharmacist would elevate the challenge to the second … resource management is to prevent work overload or situations that compromise patient care and/or lead to error … If even one team member used the appropriate skills, the problem would have been recognized and an error

62. Meeting Minutes, November 2015 | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/news/events/nac/2015-11-nac/nacmtg1115-minutes.html
    May 01, 2016 - It evaluated diagnostic error as a quality-of-care challenge and examined the epidemiology, burden of … harm, economic costs of error, and efforts to address the problem. … He described diagnostic error issues, such as the fact that diagnostic error is notoriously difficult … Dedicated funding for diagnostic error projects at AHRQ has been modest during the past dozen years. … We need longitudinal data on diagnostic error, and we need to determine error rates.

63. Diagnostic Errors Are Common in Seriously Ill Hospitalized Adults | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/news/newsletters/e-newsletter/895.html
    January 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 …

64. TeamSTEPPS Learning Benchmarks (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
    May 31, 2023 - doctor on the team make a misstatement about a sick patient, a comment that could result in a medical error … The following are human factor problems that research has identified as contributing to medical error … the right information 4 E • Two-Challenge rule • CUS (Concerned-Uncomfortable-Patient Safety) • Error … the line; resolve the confusion • Respect the input • Team dynamic • Focus on the safety, not the error … part of the team 10 B • Debrief-the word more than the concept • Deals with issues of blame and error

65. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/lepguide/lepguide.pdf
    September 01, 2012 - Identifying something as an adverse event does not imply “error,” “negligence,” or poor quality care … Most exams that are automatically scheduled are chest exams and so I performed one in error. … They do not receive training on what constitutes an error or a near miss, or on how to report these … It focuses on removing stigma associated with medical errors to allow an open environment of error … • How are hospitals addressing linguistic and cultural sources of error for LEP patients?

66. Federal Interagency Workgroup on Improving Diagnostic Safety: July Meeting Summary (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-jul2023.pdf
    November 03, 2023 - Some of these will be on diagnostic error. … https://www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1 … https://www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2

67. Developing Innovative Simulation-Based Training to Improve Patient Safety in Radiation Oncology | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/funding/grantee-profiles/grtprofile-mazur.html
    March 01, 2023 - While radiation therapy has relatively low error and injury rates, studies show that most errors occurring

68. Understanding SOPS® Surveys: A Primer for New Users - Gray (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops_101_webcast-2022-gray.pdf
    January 01, 2022 - available 15 Areas of Patient Safety Culture Assessed Across SOPS Surveys • Communication About Error … Organizational Learning – Continuous Improvement • Overall Rating on Patient Safety • Response to Error

69. Scenario 1 (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/learnbench.pdf
    February 28, 2014 - doctor on the team make a misstatement about a sick patient, a comment that could result in a medical error … The following are human factors problems that research has identified as contributing to medical error … all • Sharing the right information 4 E • Two-Challenge rule • CUS (Concerned-Patient Safety) • Error … the line; resolve the confusion • Respect the input • Team dynamic • Focus on the safety, not the error … part of the team 10 B • Debrief—the word more than the concept • Deals with issues of blame and error

70. TeamSTEPPS Learning Benchmarks | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/teamstepps/instructor/reference/learnbench.html
    March 01, 2014 - doctor on the team make a misstatement about a sick patient, a comment that could result in a medical error … The following are human factor problems that research has identified as contributing to medical error … Sharing the right information 4 E Two-Challenge rule CUS (Concerned-Patient Safety) Error … Stop the line; resolve the confusion Respect the input Team dynamic Focus on the safety, not the error … of the team 10 B Debrief-the word more than the concept Deals with issues of blame and error

71. Spanish Translation of AHRQ's Hospital Survey on Patient Safety (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital_survey_composites-spanish.pdf
    October 01, 2009 - Cuando se comete un error, pero es descubierto y corregido antes de afectar al paciente, ¿qué tan a menudo … Cuando se comete un error, pero no tiene el potencial de dañar al paciente, ¿qué tan frecuentemente es … Cuando se comete un error que pudiese dañar al paciente, pero no lo hace, ¿qué tan a menudo es reportado

72. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
    August 01, 2022 - Wu discusses this concept in his article "Medical Error: The Second-Victim" and the associated "expectation … important, even though some degree of emotional distress is likely when a clinician is involved in any error … the second-victim phenomenon even in cases where no adverse event occurred, but they feared that an error … Providers can also experience profound problems after adverse events that were not associated with medical error … During this stage, the second-victim might tell someone about the error/event as their way of asking

73. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/diagnostic-safety/workgroup/index.html
    March 01, 2024 - In Improving Diagnosis , NASEM outlined eight goals to reduce diagnostic error and improve diagnosis

74. Advancing Patient Safety | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/patient-safety/reports/advancing/index.html
    July 01, 2022 - evidence-based patient safety practices, gaining information on the requirements and effective use of medical error … It features analysis of medical error cases by recognized experts and provides interactive learning modules

75. National Academy of Medicine (NAM) Reports | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/patient-safety/reports/national-academy-medicine.html
    February 01, 2018 - Sometimes the harm is caused by an error in prescribing or taking the medication, and these damages are

76. Cuestionario sobre la de seguridad de los pacientes en los hospitales (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital_survey-spanish.pdf
    November 18, 2019 - • Un “incidente” es definido como cualquier tipo de error, equivocación, evento, accidente o desviación … Cuando se comete un error, pero es descubierto y corregido antes de afectar al paciente, ¿qué tan a … Cuando se comete un error, pero no tiene el potencial de dañar al paciente, ¿qué tan frecuentemente … Cuando se comete un error que pudiese dañar al paciente, pero no lo hace, ¿qué tan a menudo es reportado

77. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
    December 01, 2022 - “A human factors approach helps address human error by examining systemic causes rather than blaming

78. Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/topics/managing-interruptions-improve-diagnostic-decisionmaking.pdf
    December 29, 2022 - Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework

79. AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/news/newsroom/case-studies/cquips0802.html
    October 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 …

80. Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/research/findings/studies/index.html
    January 01, 2024 - temporary harm, permanent harm, or death in nearly 18% of patients; among patients who died, diagnostic error … program by developing these steps: 1) Develop a shared understanding of what constitutes a diagnostic error … case reviews; 4) Ensure reliability and consistency of the case review process; and 5) Link diagnostic error … They also developed steps to establish a diagnosis error review process at the hospital level with six