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241. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
     March 12, 2008 - 361 facilities submitted 8,862 records (4.1 percent) citing the dispensing device as the cause of error … A medication error was defined using the National Coordinating Council for Medication Error Reporting … The lorazepam administration error did not result in an adverse event for the patient, since the allergy … Automated medication dispensing systems: Not error free. J Emerg Nurs 2006; 32: 71-74. 4. … National Coordinating Council for Medication Error Reporting and Prevention; 2005 December.

242. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html
     June 01, 2023 - Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute … Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. … Families as partners in hospital error and adverse event surveillance. … The Public’s Views on Medical Error in Massachusetts. … Patients’ perspectives of diagnostic error: a qualitative study.

243. Facapplycusp (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
     June 02, 2025 - · Can you identify examples of human error in your unit or hospital? … Slide 6 SAY: To improve outcomes, human error, at-risk behavior, and reckless behavior each should … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console providers who have committed a human error and to ensure

244. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-1.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Introduction … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error

245. A Strategic Approach for Funding Research: The Agency for Healthcare Research and Quality’s Patient Safety Initiative 2000–2004 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keyes.pdf
     January 01, 2004 - Woolf, Characterizing Medical Error: A Primary Care Study). 2. … Thomas, Teamwork and Error in Neonatal Intensive Care). … Federal Government had ever made to combat medical error. … For example, five grants address the epidemiology of error as a principal goal. … Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

246. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship-references.html
     August 01, 2024 - as a Model To Improve the Quality and Safety of Diagnosis Introduction Background Diagnostic Error … in the Testing Process Diagnostic Stewardship Interventions To Reduce Diagnostic Error Diagnostic … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Analysis of diagnostic error cases among Japanese residents using diagnosis error evaluation and research … Diagnostic stewardship to prevent diagnostic error.

247. The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Jones_29.pdf
     February 23, 2008 - Results: Implementing a systematic voluntary medication error reporting program supported by specific … , and phase of the medication use system in which the error originated. … , nonpunitive response to error, and staffing. … We used a Bonferroni correction (P = 0.05/5 = 0.01) to control the Type 1 error rate due to the five … MEDMARX® National Medication Error Database (database online). United States Pharmacopeia.

248. Understanding the CMS Patient Safety Structural Measure Requirements for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/understanding-cms-patient-safety-measure-hospitals-webcast.pdf
     July 08, 2025 - Unit 16 Areas of Patient Safety Culture Assessed in Core SOPS Surveys • Communication About Error … • Organizational Learning – Continuous Improvement • Reporting Patient Safety Events • Response to Error … Staff 26 Teamwork Staffing and Work Pace Org Learning - Continuous Improvement Response to Error … Supv, Mgr, or Clinical Leader Support Communication About Error Communication Openness Reporting … X Supv, Mgr, or Clinical Leader Support X Communication About Error ✓ Communication Openness

249. Voluntary Adverse Event Reporting in Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
     January 01, 2007 - Adding “Medical Error[MESH]” or the generic term “Error” to searches narrowed them considerably, but … Wrong drug name 15 1.71 2.20 0 – 2.67 2.48 Wrong dose of drug Medication error Wrong dose 16 1.82 … Error in medicine. JAMA 1994; 272: 1851-1857. 3. Leape LL, Brennan TA, Laird N, et al. … Promoting patient safety by preventing medical error. JAMA 1998; 280:1444-1447. 11. … Pediatric medication order error rates related to the mode of order transmission.

250. /docProps/thumbnail.jpeg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module1/facnotes-spanish.docx
     June 02, 2025 - humano: Cometer sin querer un desacierto; una equivocación, un descuido o un error. · Comportamiento … · El error humano es producto del diseño del sistema y las decisiones de comportamiento. … El error humano se puede manejar a través de cambios de procesos, procedimientos, capacitación, diseño … El enfoque de manejo adecuado es consolar a los integrantes del equipo que cometieron un error humano … humano: Cometer sin querer un desacierto: una equivocación, un descuido, un error Comportamiento de

251. Content-Specific Versus Process-Focused Checklists | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-3.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Content-Specific Versus … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Sibbald and colleagues found in several studies that the use of this checklist reduced diagnostic error

252. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Ginsberg (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-new_sops_diagnostic_safety-ginsberg.pdf
     June 02, 2025 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management

253. New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals - Ginsberg (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-new-sops-workplace-safety-ginsberg.pdf
     June 02, 2025 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management

254. Final Progress Report: Improving Patient Safety by Reducing Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/strom2-report.pdf
     January 01, 2024 - Key Words: medication safety, medication error, medical error, patient safety 5P01HS011530-05 Strom … Only the initial hospitalization due to a medication error was included. … We use these three measures as our indications of error/near misses. … However, nine error risks remained unchanged, three were addressed but offsetting error risks emerged … , two error-reducing functions were eliminated, and six new error risks were introduced.

255. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 1: Why Patient Narratives Matter (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
     July 01, 2023 - Hopkins University Christina Yuan Johns Hopkins University Helen Haskell Mothers Against Medical Error … The patient is in: patient involvement strategies for diagnostic error mitigation. … Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. … Patients’ perspectives of diagnostic error: a qualitative study. … The Public’s Views on Medical Error in Massachusetts.

256. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
     March 01, 2024 - Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating … 23 percent of patients treated at 29 academic medical centers in the U.S. experienced a diagnostic error … by Agency-funded research teams that have published essential insights into areas such as diagnostic error

257. Establishing a Culture of Patient Safety Through a Low-tech Approach to Reducing Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Shaha.pdf
     May 01, 2004 - Each order was analyzed for any type of prescribing, dispensing, administering, or documentation error … , and each discovered error was documented in detail, regardless of whether or not it resulted in patient … The Medication Error Reduction: A Low-tech Approach 337 CPQ staff designed and implemented the … Third, the FFF was paper-based, and underscored the truism that prescribing can be made near error- … Through the CHAI medication error study and the other projects undertaken by CPQ, the concept and practice

258. Presentation Slides | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/apply/sl-cusp.html
     December 01, 2012 - Managing Error and Risk Slide 8. … Understanding Risk and Human Behavior 1 Human Error: Inadvertently completing the wrong action … Managing Error and Risk 1 Human Error Product of our current system design and behavioral choices … Describe the connections between communication and medical error.

259. Final Progress Report: Proactive Risk Reduction in Medication Prescribing in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
     January 01, 2024 - Each brainstorming session was designed to construct a fault tree for one specific proximal error in … to occur: Proximal Error % of Drug Orders with this Error prescribing a drug for which the patient … and no points in the clinic’s system at which the path to the proximal error would be blocked. … This was particularly important for the inadequate laboratory monitoring error. … Thus, the lack of redundancy found in the fault tree for this error was a major finding.

260. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - A “medical error” is defined as the failure of a planned action to be completed as intended (error … Numerous studies have documented the impact of human error on patient safety. … Human error. New York: Cambridge University Press; 1990. 7. Reason J. … Human error: models and management. BMJ 2000;7237:768–70. 8. Ternov S. … Error reduction as a systems problem. In: Bogner, MS, editor. Human error in medicine, pp.67– 91.