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1961. 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.

1962. 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

1963. 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…

1964. 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…

1965. 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

1966. 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

1967. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-slides.html
      July 01, 2023 - Slide 15: Understanding Risk and Human Behavior 3 Image: Human Error refers to inadvertently doing … Slide 16: Managing Error and Risk 3 Image: Three text boxes contain the following: Human Error

1968. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
      May 01, 2011 - Wu discusses this concept in his article “Medical Error: The Second-Victim” and the associated “expectation … the second-victim phenomenon even in cases where no adverse event occurred, but they feared that an error … stage. 9 Stage 1: Chaos and Accident Response Stage characterized by the second-victim: Realizing error … During this stage, the second-victim might tell someone about the error/event as their way of asking … Medical error: the second victim. The doctor who makes the mistake needs help too.

1969. 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…

1970. Tool: Task Assistance | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/mutual/tools/task.html
      May 01, 2023 - Vulnerability to error is increased when people are under stress, are in high-risk situations, and are … which it is expected that assistance will be actively sought and offered to reduce the occurrence of error

1971. Selected Best Practices and Suggestions for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
      May 20, 2016 - with drug reaction ∗ Death associated with adverse drug reaction ∗ Death associated with medication error … Procedures  Prophylaxis  Resuscitation  Supervision/management  Triage/transitions  Human error … usual procedures performed in accordance with standards of care) and nosocomial infections  Human error … Multi-professional mortality review: supporting a culture of teamwork in the absence of error finding

1972. 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…

1973. Regulation of Health Policy: Patient Safety and the States (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
      March 01, 2004 - (The abbreviation AE will be used throughout the paper to denote “adverse event,” “medical error,” etc … The California medication error reporting system requires the Office of Statewide Health Planning and … NASHP notes that the most frequent use of data from incident or error reports is aggregating data to … Marchev M., Medical malpractice and medical error disclosure: balancing facts and fears. … How many deaths are due to medical error? Getting the number right.

1974. 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…

1975. Improving the Value of Patient Safety Reporting Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
      June 12, 2008 - If the second nurse finds an error, is this a reportable event? … Epidemiology of medical error. Br Med J 2000; 320: 774-777. 7. Leape L, Berwick D, Bates D. … A systems analysis approach to medical error. J Eval Clin Pract 1997; 3: 213-222. 21. … Perceived barriers to medical error reporting: An exploratory investigation. … Analysing medical incident reports by use of a human error taxonomy.

1976. Strategies for Improving Patient Safety in Small Rural Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Tupper_73.pdf
      March 20, 2008 - the extent to which it emphasizes the importance of patient safety, facilitates open discussion of error … , encourages error reporting, and creates an atmosphere of continuous learning and improvement. … For example, one hospital initiated system changes for error-reporting by soliciting employee suggestions … 53 68a 52 62 Nonpunitive response to error 35 50a 43 43 Staffing 46 52a 50 55 Hospital management … response to error, and open communication.

1977. Assess and Adapt: Understanding the Science of Safety and Reliability | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-slides.html
      July 01, 2018 - Slide 5 Health Care Defects 7 percent of patients suffer a medication error 2 On average, every … Slide 17 System Failures Leading to Error (Reason, 1990) Image: Four chunks of swiss cheese with … Human Error. New York, NY: Cambridge University Press, 1990. Heifetz R.

1978. 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

1979. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
      September 03, 2014 - By identifying the defect or error, the team can engage in a multidisciplinary discussion of causes or … error.     16 Principles of Safe Design Apply to Technical/Clinical Work and Teamwork Standardize … A defect is any error or process that stands in the way of meeting your quality improvement goals. … Human Error. Cambridge: University Press; 1990. … The impact of medication error reduction.

1980. 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…