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2501. 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…

2502. 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…

2503. 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 …

2504. Diagnostic Safety Resource List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
      May 01, 2023 - is to create a well-organized office system that fosters sound medical decision making, minimizes error … www.improvediagnosis.org/practice-improvement-tools/open-notes/ Open Notes addresses multiple aspects of diagnostic error … AudioandVideo/WIHIImprovingDiagnosisErrors.aspx In this podcast from IHI, four speakers discussed diagnostic error … kp_shortcut_referrer=kp.org/scal/dex The videos in this series are short and cover a wide range of diagnostic error … and educators on clinical reasoning, critical thinking, and system factors that underlie diagnostic error

2505. Medical Injury Identification Using Hospital Discharge Data (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
      January 01, 2003 - While the IOM report primarily emphasized error reporting systems, focusing on the injuries or adverse … Most current patient safety reporting systems focus on incidence of medical error or negligence. … Perceived blame and punishment for error, however, may be an incentive for concealment and denial. … those resulting from malpractice damages.2 In addition, the determination of negligence or medical error … believe this injury prevention approach is a useful complement to other approaches that focus on error

2506. Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Dickerman_84.pdf
      June 04, 2008 - cold” by the Institute of Medicine’s (IOM) 1999 report, To Err Is Human.2 1 The Nature of Error … established the theoretical basis for this understanding through their work in the study of human error … The unit cost per life saved is enormous. 2 How the Environment Contributes to Error What … Error in medicine. JAMA 1994; 272: 1851- 1857. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. … Human error. Cambridge, UK: Cambridge University Press; 1990. 4. Perrow C.

2507. 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.

2508. Chapter 1. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2014/mosurv14chap1.html
      June 01, 2014 - research pertaining to safety, patient safety, health care quality, ambulatory medicine, medical errors, error … It was designed to assess medical office staff opinions about patient safety issues, medical error, and

2509. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
      June 18, 2008 - patients receiving PCA therapy and implementation of “smart” (computerized) PCA pumps containing dose-error … Our multidisciplinary Medication Error Team includes pharmacists, respiratory therapists, risk managers … team determined that implementation of a modular, computerized IV infusion safety system with dose error … PCA Practice and Patient Monitoring Recognizing opioids’ potential for harm, the Medication Error Team … Conclusion Data indicate that the use of “smart” PCA infusion devices with dose error-reduction systems

2510. 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

2511. 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…

2512. 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…

2513. 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

2514. 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

2515. 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…

2516. 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.

2517. 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…

2518. 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

2519. 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…

2520. 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