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2341. Case 3. Grand Hospital Center | Agency for Healthcare Research and Quality
      www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case3.html
      November 01, 2014 - some frustration that data collection is time consuming and, if done manually, can introduce human error

2342. 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…

2343. 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.

2344. 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.

2345. 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…

2346. 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.

2347. 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.

2348. 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

2349. 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.

2350. Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Borowitz_4.pdf
      January 22, 2008 - Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World Stephen M. Borowitz, MD, Linda A. Waggoner-Fountain, MD, Ellen J. Bass, PhD, and Justin M. DeVoge, MS Abstract Background: Sign-out is a …

2351. Public Reporting of Patients’ Comments with Quality Measures: How Can We Make It Work? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140603_QI/reporting-patients-comments-transcript.pdf
      June 01, 2014 - Public Reporting of Patients’ Comments with Quality Measures: How Can We Make It Work? Public Reporting of Patients’ Comments with Quality Measures: How Can We Make It Work? June 2014  Webcast Speakers Steven Martino, PhD, Behavioral Scientist, RAND, Pittsburgh, PA Rachel Grob, PhD, Senior Scientist, Cent…

2352. 050-Dec-Implementation-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/050-dec-implementation-notes.docx
      October 01, 2024 - AHRQ Safety Program for MRSA Prevention Implementation of Chlorhexidine Gluconate (CHG) Bathing and Nasal Decolonization ICU & Non-ICU Slide Title and Commentary Slide Number and Slide Implementation of Chlorhexidine Gluconate (CHG) Bathing and Nasal Decolonization SAY: Welcome to this presentation on the implemen…

2353. Paul Tedrick (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/mindfulness-transcript.doc
      June 10, 2014 - Paul Tedrick AHA – Chicago June National Content Call June 10, 2014 11:00 AM CT Operator: The following is a recording of the Paul Tedrick June National Content Call with the American Hospital Association on Tuesday, June 10, 2014 at 11:00 a.m. Central Time. Excuse me, everyone. We now have all of our speakers in c…

2354. Mindfulness: Engaging Frontline Providers in Antimicrobial Stewardship (June 10, 2014) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/mindfulness-transcript.html
      December 01, 2017 - Mindfulness: Engaging Frontline Providers in Antimicrobial Stewardship (June 10, 2014) Webinar Transcript AHA – Chicago June National Content Call June 10, 2014 11:00 AM CT Operator: The following is a recording of the Paul Tedrick June National Content Call with the American Hospital Association on …

2355. Advancing the Science and Implementation of Patient Narratives: Summary of Presentations (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-patient-narratives-presentations-summary.pdf
      January 01, 2022 - Advancing the Science and Implementation of Patient Narratives: Summary of Presentations Advancing the Science and Implementation of Patient Narratives: Summary of Presentations October 7, 2021 Patient Narratives Research Meeting: Summary 2 Introduction and Overview ..........................................…

2356. Creative Strategies to Improving Patient Care Experience Webcast Transcript (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-creative-strategies-transcript.pdf
      April 01, 2019 - Creative Strategies to Improving Patient Care Experience Webcast Transcript  Creative Strategies to Improve Patient Care Experience April 2019 Webcast Speakers Caren Ginsberg, PhD, CPXP, Director, CAHPS Division, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality I…

2357. Final Progress Report: Failure To Rescue-Patient Safety Learning Lab (FTR-PSLL) (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/blike-report.pdf
      January 01, 2025 - Final Progress Report: Failure To Rescue-Patient Safety Learning Lab (FTR-PSLL) Title of Project: Failure to Rescue-Patient Safety Learning Lab (FTR-PSLL) Principal Investigator and Team Members: Dartmouth-Hitchcock: George Blike, MD, MHCDS, PI; Susan McGrath, PhD, CoI; Todd McKenzie, PhD; Irina Pearrard, PhD…

2358. Chartbook on Effective Treatment: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/effectivetreatment-slides.html
      April 01, 2018 - 1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR … visits for MHSA, as ED overcrowding can reduce quality of care and increase the likelihood of medical error

2359. 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…

2360. Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2018, Technical Documentation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/2018-Compendium-TechDoc-update.pdf
      January 01, 2018 - Data on offering an MA product can differ across the two sources for four reasons: (1) measurement error … Potential measurement error in AHA survey responses.