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1201. PS Grantee | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/index.html?page=18
      January 01, 2024 - Patient and Family Engagement Publication Date: September 2005 Malpractice Insurers’ Medical Error … September 2005 Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error

1202. Mod4-System-Focused-Event-Guide (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
      April 01, 2016 - 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. … If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … – Ask questions such as “Why was there human error? … ■ Were there features of the device that facilitated error?

1203. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
      April 20, 2004 - of paper MARs in tandem with electronic BCMA documentation) increase the probability of medication error … of PRN medications for CABG patients were documented in the BCMA system, so the risk of medication error … Patient Safety: Vol. 3 448 Cultural and management issues Elimination of a punitive medication error … Following root-cause analysis of the barriers to the BCMA software implementation, the medication error … errors was an option only when the error was associated with a criminal or purposefully unsafe act

1204. Action Planning for the SOPS Surveys Webcast Transcript (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/action-planning-webcast-transcript.pdf
      June 01, 2019 - We are below the database on Feedback and Communication About Error, Nonpunitive Response to Error and … , Staffing, Nonpunitive Response to Error, and Handoffs and Transitions. … We've also increased our Nonpunitive Response to Error from 30% positive to 41% positive. … While we're below the database and similar sized hospitals on Nonpunitive Response to Error, we have … Feedback and Communication About Error is the extent to which staff are informed about errors.

1205. Shadowing Another Professional Tool | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/shadowing.html
      December 01, 2012 - Did you observe any error in transcription of orders by the provider you shadowed?       … Did you observe any error in the interpretation or delivery of an order?       5.

1206. Chapter 1. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2014/mosurv14chap1.html
      June 01, 2014 - research pertaining to safety, patient safety, health care quality, ambulatory medicine, medical errors, error … It was designed to assess medical office staff opinions about patient safety issues, medical error, and

1207. Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
      June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Intr…

1208. Conclusions | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-5.html
      June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Conclusions Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introducti…

1209. Use of Data and Measurement in Improving Diagnostic Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/newman-toker-summit2016.pdf
      September 28, 2016 - clinical data warehouses (+/- supported by NLP) HELP MEASURE & TRACK PROBLEMS BIG DATA FOR DX ERROR … NUMERATOR-ONLY Methods NUMERATOR-DENOMINATOR Methods NUMERATOR-DENOMINATOR Methods Big data for Dx Error

1210. Diagnostic Safety Resource List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
      May 01, 2023 - is to create a well-organized office system that fosters sound medical decision making, minimizes error … www.improvediagnosis.org/practice-improvement-tools/open-notes/ Open Notes addresses multiple aspects of diagnostic error … AudioandVideo/WIHIImprovingDiagnosisErrors.aspx In this podcast from IHI, four speakers discussed diagnostic error … kp_shortcut_referrer=kp.org/scal/dex The videos in this series are short and cover a wide range of diagnostic error … and educators on clinical reasoning, critical thinking, and system factors that underlie diagnostic error

1211. Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Dickerman_84.pdf
      June 04, 2008 - cold” by the Institute of Medicine’s (IOM) 1999 report, To Err Is Human.2 1 The Nature of Error … established the theoretical basis for this understanding through their work in the study of human error … The unit cost per life saved is enormous. 2 How the Environment Contributes to Error What … Error in medicine. JAMA 1994; 272: 1851- 1857. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. … Human error. Cambridge, UK: Cambridge University Press; 1990. 4. Perrow C.

1212. Medical Injury Identification Using Hospital Discharge Data (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
      January 01, 2003 - While the IOM report primarily emphasized error reporting systems, focusing on the injuries or adverse … Most current patient safety reporting systems focus on incidence of medical error or negligence. … Perceived blame and punishment for error, however, may be an incentive for concealment and denial. … those resulting from malpractice damages.2 In addition, the determination of negligence or medical error … believe this injury prevention approach is a useful complement to other approaches that focus on error

1213. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-2.html
      June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Introduction Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introduct…

1214. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
      June 18, 2008 - patients receiving PCA therapy and implementation of “smart” (computerized) PCA pumps containing dose-error … Our multidisciplinary Medication Error Team includes pharmacists, respiratory therapists, risk managers … team determined that implementation of a modular, computerized IV infusion safety system with dose error … PCA Practice and Patient Monitoring Recognizing opioids’ potential for harm, the Medication Error Team … Conclusion Data indicate that the use of “smart” PCA infusion devices with dose error-reduction systems

1215. St. Jude Relies on AHRQ's Hospital Survey on Patient Safety Culture | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/cquips1402.html
      January 01, 2014 - "It's not about blaming them that an error occurred." … These dimensions include nonpunitive response to error, communication openness, hospital management support

1216. Conclusion | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-5.html
      June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Conclusion Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introductio…

1217. Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.html
      June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Intr…

1218. Directions for Future Research | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-4.html
      June 01, 2023 - move away from previous practices of asking respondents if they experienced medical or diagnostic “error

1219. Spanish Translation of AHRQ's Hospital Survey on Patient Safety (pdf file)
      www.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

1220. Learning From Narratives About Diagnostic Experience | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-4.html
      June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Learning From Narratives About Diagnostic Experience Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnosti…