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preventiveservices.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/medication/safe-medication-slides.html
July 01, 2023 - medications are "drugs that bear a heightened risk of causing significant patient harm when they are used in error … 6,7
Use of a uniform mixed preparation unitwide for all patients to reduce variability and risk for error
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preventiveservices.ahrq.gov/sops/about/faq/index.html
June 01, 2022 - of 2 to 4 survey items that assess the same area of patient safety culture):
Communication About Error … Learning—Continuous Improvement (3 items)
Reporting Patient Safety Events (2 items)
Response to Error … Feedback & Communication About Error.
Frequency of Events Reported. … Nonpunitive Response to Error.
Organizational Learning-Continuous Improvement. … The composite measures in the medical office survey are:
Communication About Error.
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preventiveservices.ahrq.gov/teamstepps-program/curriculum/intro/explain.html
July 01, 2023 - Patient harms can occur for many reasons, and a single error can often be linked to a number of causal … is based on evidence derived from teams working in high-risk environments where the consequences of error
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preventiveservices.ahrq.gov/teamstepps/instructor/scenarios/combatcare.html
March 01, 2014 - before administering the medication and the resident's situation awareness and cross-monitoring break an error … chain that could have resulted in a medication dosage error for the patient. … Although not life threatening, the error placed the patient at unnecessary risk, delayed his disposition … appropriately raises the question again, which results in the correction of a potential medication error
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preventiveservices.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety-fac-guide.html
July 01, 2023 - Skip to main content
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November 01, 2020 - Top of Page
M
Medical Error: An unintended but preventable adverse effect of care, whether or
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July 01, 2023 - Errors
Two new AHRQ issue briefs describe the importance of patient engagement after a diagnostic error
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preventiveservices.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-slides.html
July 01, 2023 - Health Care Defects
In the U.S. health care system—
7 percent of patients suffer a medication error
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
March 01, 2013 - System/provider error.
Intentional nonadherence. … System/provider error. When the hospital did not do something it was supposed to.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
July 01, 2018 - existing surveys, pertaining to patient safety, hospital
medical errors and quality-related events, error … Nonpunitive Response to Error Staff feel that their mistakes and event reports are not held
against … This can contribute to response error if
respondents overlook parts of the survey, and it may annoy … An “event” is defined as any type of error, mistake, incident, accident, or
deviation, regardless … Feedback & Communication About Error
(Never, Rarely, Sometimes, Most of the time, Always)
C1.
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preventiveservices.ahrq.gov/hai/cusp/toolkit/content-calls/briefing-slides/slides.html
October 01, 2014 - Sections 3-5
Did you observe an error in transcription of orders by the provider you followed? … Did you observe an error in the interpretation or delivery of an order?
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preventiveservices.ahrq.gov/teamstepps/instructor/scenarios/labordel.html
March 01, 2014 - situation awareness in that the monitoring individual takes action to interrupt or avoid an impending error … The anesthesiologist looks at his hands, notices the error, and corrects it. … The nurse is able to provide the appropriate support to the anesthesiologist by alerting him to the error … The OB, realizing his error, takes corrective action. … The error occurs when the team dismisses this information and is allowed to continue on their current
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preventiveservices.ahrq.gov/teamstepps-program/index.html
Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error