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221. Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Zhang.pdf
     January 01, 2004 - [Message] Good error messages. … [Error] Prevent errors. … cause error.25, 26 For example, an isolated step in a task affords error, such as the step of entering … internal, the higher the error affordance because internal representations are more error prone. … Medical Device Usage Errors 335 established a strong correlation between error affordance and error

222. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxchecklists-7.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction References … Previous Page   Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Debiasing versus knowledge retrieval checklists to reduce diagnostic error in ECG interpretation. … Developing checklists to prevent diagnostic error in Emergency Room settings. … Human Error. Cambridge, UK: Cambridge University Press; 1990. Return to Contents

223. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-7.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction References … Previous Page   Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Debiasing versus knowledge retrieval checklists to reduce diagnostic error in ECG interpretation. … Developing checklists to prevent diagnostic error in Emergency Room settings. … Human Error. Cambridge, UK: Cambridge University Press; 1990. Return to Contents

224. Appendix F. Algorithms | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ssi/ssiapf.html
     April 01, 2018 - Correlation and Cross-validation error for CABG Algorithm Return to Contents Figure 3. … Correlation and Cross Validation Error for Herniorrhaphy Return to Contents Figure 5. … Correlation and Cross Validation Error for TKA Return to Contents Figure 7. … Correlation and Cross Validation Error for THA Return to Contents Algorithms That Include sSSI

225. Final Progress Report: Staff Nurse Fatigue and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/rogers-report.pdf
     January 01, 2024 - Working longer than 12.5 consecutive hours was associated with a significantly higher risk of error, … Short sleep durations were also associated with an increased risk of making an error and difficulties … and almost doubled the risk of making error among critical care nurses (AACN Sample). … Fatigue, performance, and medical error. In: Bogner MS, ed. Human error in medicine. … Human error in medicine. Hillsdale, N.J.: Lawrence Erlbaum Associates; 1994:13-25. 12.

226. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - the ICU to the general ward face numerous obstacles, placing them at significant risk for diagnostic error … focus on clinical criteria such as ICU readmissions, few focus explicitly on preventing diagnostic error … embedding diagnostic pauses, and measuring post discharge diagnostic outcomes can mitigate diagnostic error

227. The Use of Surgical Simulators to Reduce Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Fried.pdf
     January 01, 2003 - Error reduction and surgical expertise can be achieved through the implementation of a dynamic, simulation-based … Errors in ESS were identified, and each error was classified according to a taxonomy of error types … Quantifiable measures then were defined for each error. … This rigorous process has brought to the project an added emphasis on error reduction prevention as … uniform and comprehensive manner precisely what the errors are and how to avoid them.23 The key to error

228. Grand Rounds Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
     August 01, 2022 - programs, but many struggle to ensure that solutions to errors are really addressing the cause of the error … and not just checking the box on their process when they do their analysis of the error. … In Rosemary Gibson's book: Responding to medical error is a part of health care where we should be … Being shamed or blamed for the error. Revealing poor skills/abilities.   … This is a cornerstone of the CANDOR process of investigating the root cause of how an error occurred,

229. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2019.xlsx
     January 01, 2019 - The tables include the relative frequencies by type of device, by device defect, failure or use error … Percentage Frequency Device defect or failure, including HIT 38.4% 1,429 Unknown 34.2% 1,273 Use error … 21.4% 797 Combination or interaction of device defect or failure and use error 5.9% 220 Device_5 … Frequency Device defect or failure, including HIT 41.3% 668 35.0% 114 Unknown 28.3% 458 27.3% 89 Use error … 23.7% 384 27.9% 91 Combination or interaction of device defect or failure and use error 6.7% 108 9.8%

230. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2023.xlsx
     January 01, 2023 - The tables include the relative frequencies by type of device, by device defect, failure or use error … Total Unknown 57.1% 19,960 34,962 Device defect or failure, including HIT 30.1% 10,531 34,962 Use error … 8.9% 3,124 34,962 Combination or interaction of device defect or failure and use error 3.9% 1,347 34,962 … defect or failure, including HIT 90.9% 2664 9.1% 266 8,236 Unknown 93.4% 3329 6.6% 235 8,236 Use error … 83.6% 1016 16.4% 199 8,236 Combination or interaction of device defect or failure and use error 82.5%

231. Clinical Inertia and Outpatient Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
     January 01, 2003 - Subsequent actions are also in error, since knowledge of appropriate thresholds fails to cover future … Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel

232. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2022.xlsx
     January 01, 2022 - The tables include the relative frequencies by type of device, by device defect, failure or use error … Total Unknown 57.4% 19,816 34,494 Device defect or failure, including HIT 30.0% 10,349 34,494 Use error … 8.8% 3,029 34,494 Combination or interaction of device defect or failure and use error 3.8% 1,300 34,494 … defect or failure, including HIT 91.4% 2560 8.6% 242 7,932 Unknown 93.9% 3289 6.1% 215 7,932 Use error … 84.2% 959 15.8% 180 7,932 Combination or interaction of device defect or failure and use error 83.6%

233. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2020.xlsx
     January 01, 2020 - The tables include the relative frequencies by type of device, by device defect, failure or use error … Total Unknown 49.7% 7,192 14,476 Device defect or failure, including HIT 33.5% 4,846 14,476 Use error … 12.4% 1,798 14,476 Combination or interaction of device defect or failure and use error 4.4% 640 14,476 … defect or failure, including HIT 41.3% 839 35.3% 147 2,447 Unknown 27.4% 557 24.8% 103 2,447 Use error … 24.1% 489 29.1% 121 2,447 Combination or interaction of device defect or failure and use error 7.2%

234. Cuestionario sobre la seguridad de los pacientes en las farmacias en su comunidad (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/toolkit/pharmform_span.pdf
     July 11, 2014 - ► Un error es cualquier tipo de equivocación o error en el medicamento, o cualquier incidente relacionado … Cuando ocurre un error, tratamos de averiguar los problemas en los procesos que dieron lugar al error … Cuando un error sigue ocurriendo, cambiamos la manera en que se trabaja ........ 1 2 3 4 5 9 6. … Cuando el paciente recibe un medicamento con algún error que podría causarle daño al paciente pero … Cuando el paciente recibe un medicamento con algún error que no tiene la posibilidad de causar daño

235. Cuestionario sobre la seguridad de los pacientes en las farmacias en su comunidad (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-survey-spanish.pdf
     July 11, 2014 - ► Un error es cualquier tipo de equivocación o error en el medicamento, o cualquier incidente relacionado … Cuando ocurre un error, tratamos de averiguar los problemas en los procesos que dieron lugar al error … Cuando un error sigue ocurriendo, cambiamos la manera en que se trabaja ........ 1 2 3 4 5 9 6. … Cuando el paciente recibe un medicamento con algún error que podría causarle daño al paciente pero … Cuando el paciente recibe un medicamento con algún error que no tiene la posibilidad de causar daño

236. Applying Human Factors to Make it Easier for Clinicians to Do Their Jobs | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-miller.html
     August 01, 2022 - health information technology,  and other factors that can increase a woman’s risk of a CVD diagnostic error … The potential for a CVD diagnostic error can begin as soon as women describe their symptoms, according … team is studying the role of the ambulatory care environment in elevating the risk of a CVD diagnostic error … that clinicians use to help them predict CVD risk itself can be a contributing factor to diagnostic error … a human factors engineering approach cannot identify an overall formula for reducing CVD diagnostic error

237. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxchecklists-5.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Why Checklists for … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Successful checklists for preventing other error types list very specific tasks.

238. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Why Checklists for … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Successful checklists for preventing other error types list very specific tasks.

239. Tool: Cross-Monitoring | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
     June 01, 2023 - Cross-monitoring is a harm and error reduction strategy that involves: Monitoring actions of other … Instead, it is a way to provide a safety net or an error prevention or error interruption mechanism for

240. The Potential of Psychological Safety and Organizational Safety Culture To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-psychological-safety-2.html
     September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … It is reasonable, however, to think that the principles that enable error reporting and guide process