Results

Total Results: 2,910 records

Showing results for "error".
Users also searched for: medication errors

261. 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.

262. 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.

263. /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

264. 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.

265. 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

266. 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

267. 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

268. 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

269. 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.

270. 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.

271. 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.

272. Diagnostic Stewardship in Action | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship6.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 … mismanagement of a correctly diagnosed patient, such incidents could also result from a diagnostic error … To the extent that diagnostic error contributes to inappropriate use of transfusion, diagnostic stewardship

273. Learn-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-facilitator-guide.docx
     May 01, 2017 - Can you identify examples of human error in your unit or hospital? … Slide 15 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

274. Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
     January 01, 2024 - Scope Institute of Medicine (2004) reports on patient safety and medical error have led to an emphasis … Research suggests at least 10% of administered doses of medication result in error (Barker & Allan, … health information technology (HIT) to support the delivery of medication, enhanced adverse event and error … workarounds can lead to medical errors, there has been little attempt to examine changes in risk of error … On the other hand, workarounds of these blocks may make the system vulnerable to error and increase

275. Clarification in Using Different Paradigms and Terms for Improvement Efforts | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology6.html
     April 01, 2025 - standards used to assess care established a priori, before an event, or was something declared to be “an error … How were judgments of “error” and preventability determined?

276. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patient-role-references.html
     September 01, 2024 - Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; National … Burden of serious harms from diagnostic error in the USA. … The patient is in: patient involvement strategies for diagnostic error mitigation. … Diagnostic error experiences of patients and families with limited English-language health literacy or … Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; National

277. On-line Patient Safety Climate Survey: Tool Development and Lessons Learned (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Connelly.pdf
     January 01, 2003 - New safety and error reduction standards for hospitals. … Error in medicine. JAMA 1994;272:1851–7. 7. Leape LL, Simon R, Kizer WK, et al. … Reducing medical error: can you be as safe in a hospital as you are in a jet? … Error, stress, and teamwork in medicine and aviation: cross sectional surveys. … Improving quality, minimizing error: making it happen. Health Aff 2001;20(3):68–81. 16.

278. Final Report: Improving Drug Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/magid-report.pdf
     January 01, 2024 - Key Words: Medication safety, pharmacy, decision support, alert systems, error reduction Improving … Although the methodological quality of the research is variable, error reduction strategies with some … Improving Drug Safety 1 UC1 HS14249 9 Most medication error reduction strategies have focused … If PIMS detected a possible error in lab monitoring, then a medication alert was issued, but, unlike … First, most medication error prevention programs have been studied in the inpatient setting.

279. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - patient safety"[All Fields] OR "safety culture"[All Fields] OR "systems approach"[All Fields] OR "medical error … Fields] OR "medical mistake*"[All Fields] OR "adverse event*"[All Fields] OR checklist ((medical error … surveillance [mh] OR safety [mh] OR (adverse [ti] AND (drug* [ti] OR event* [ti])) OR (medication* [ti] AND (error

280. Final Progress Report: Ambulatory Pediatric Patient Safety Learning Lab: Pursuing Safe Healthcare at Home (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/walsh-kirkendall-report.pdf
     January 01, 2025 - Inter-rater reliability for error occurrence was 100%. 2,35,36 Inter-rater reliability for error occurrence … We summarized demographics and error rates using descriptive statistics. … The most common error participants made was management of ketones (Table 3). … Type and Frequency of Errors in Simulated Sick Day Scenarios Error type # with error Insulin dosing … error, n (%) 3 (25) Technology error, n (%) 2 (17) Ketone management error, n (%) 5 (42) Treatment