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2361. Identifying and Ranking Defects | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/videos/05f-rank-defects/index.html
      July 01, 2018 - Identifying and Ranking Defects CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit.   Identif…

2362. Identifying Contributing Factors | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/videos/05d-contrib-factors/index.html
      June 01, 2018 - Identifying Contributing Factors CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit. Identifyin…

2363. Account for Variability | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/videos/10d-account-variability/index.html
      June 01, 2018 - Account for Variability CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit. Account for Variabi…

2364. Factors That Affect Spread | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/videos/10b-impact-spread/index.html
      June 01, 2018 - Factors That Affect Spread CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. Factors That Affect Spread [6 min. 8 sec.] YouTube embedded video: https://www.youtube-nocookie.…

2365. Using the Daily Goals Checklist | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/videos/06d-using-daily-goals/index.html
      June 01, 2018 - Using the Daily Goals Checklist CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit. Daily Goals…

2366. Understand Just Culture | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/videos/07a-just-culture/index.html
      July 01, 2018 - Understand Just Culture CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit. Understand "Just Cu…

2367. Teams Make Wise Decisions With Diverse and Independent Input | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/videos/04g-diverse-input/index.html
      June 01, 2018 - Teams Make Wise Decisions With Diverse and Independent Input CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the C…

2368. Identify Your Unit’s Safety Issues | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/videos/05a-id-unit-safety-issues/index.html
      June 01, 2018 - Identify Your Unit’s Safety Issues CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit. Identify…

2369. Learn From Defects | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/videos/04e-learn-defects/index.html
      June 01, 2018 - Learn From Defects CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit. Learn From Defects [2 m…

2370. 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

2371. 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

2372. 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

2373. Evidence Base Supporting Telehealth | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/teledx-2.html
      August 01, 2020 - nonurgent complaints in primary care settings, diagnostic accuracy and the likelihood of diagnostic error

2374. 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…

2375. 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.

2376. 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

2377. 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.

2378. 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.

2379. 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.

2380. 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.