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321. Chapter 6. Assessment and Process Evaluation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/chapter-6.html
     July 01, 2022 - Special Considerations: The National Coordinating Council for Medication Error Reporting and Prevention … This index considers factors such as whether the error reached the patient and, if the patient was harmed … Table 6 explains the different categories of medication error classification. … Different categories of medication error classification were adapted into the table below.

322. TeamSTEPPS® Diagnosis Improvement: Module 7: Putting It All Together (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module7-presenters-notes.pdf
     January 01, 2008 -                                                                             • Summarize diagnostic error … Slide 3 Diagnostic Error Is a Patient Safety Issue Getting  the  right  diagnosis  in  a  timely … Diagnostic error is a patient safety issue. … Every member of the team can help prevent a diagnostic error. … It is an effective antidote to many of the problems that lead to diagnostic error: overconfidence,

323. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
     August 01, 2023 - Diagnostic Error in Pediatrics: A Narrative Review. Pediatrics . … Diagnostic error in children presenting with acute medical illness to a community hospital. … Committee on Diagnostic Error in Health Care. Improving diagnosis in health care. … Primary care pediatricians' interest in diagnostic error reduction. Diagnosis (Berl) . … Factors Associated With Diagnostic Error on Admission to a PICU: A Pilot Study.

324. Catheter-Care-Quiz (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-care/catheter-care-quiz.docx
     March 01, 2017 - Determine the catheter care error. … Determine the catheter care error.

325. Final Progress Report: Automated Medical Interviewing for Diagnostic Decision Support in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/newman-toker2-report.pdf
     January 01, 2025 - Usability (Ease of Use, Error, Efficiency) Ease of use, error rate, and efficiency analyses are summarized … Time per click was not associated with error based on age entry misclick rates. … Second, certain usability design features had more influence on the error rate than others. … Those with access demonstrated greater ease of use, lower error rates, and improved efficiency. … Implications for decision support and error reduction. JGenInternMed. 2005;20(4):334-9. 17.

326. Module 2: Communication and Optimal Resolution (CANDOR) Toolkit Module 2: Obtaining Organizational Buy-in and Support
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/module2-obtaining-organizational-buy-in-support.pptx
     August 14, 2015 - Reckless behavior—Choosing to consciously disregard a substantial and unjustifiable risk. 9 Managing Error … and Risk5,6 Module 2 10 To improve outcomes, human error, at-risk behavior, and reckless behavior … 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

327. Understanding SOPS Surveys: A Primer for New Users - Gray (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-3-gray-2018.pdf
     January 01, 2018 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management … supports accurate diagnoses – Conduct research to assist in identifying processes and sources of error

328. Using the AHRQ Medical Office Survey on Patient Safety Culture Webinar - Hickner (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/hickner-development-medical-office-sops.pdf
     January 01, 2011 - Feedback & communication about error 3. Frequency of event reporting 4. … Nonpunitive response to error 7. Organizational learning--continuous improvement 8. … Communication about error 12.

329. Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/anesthesia-medication-long-desc.html
     January 01, 2025 - The learning lab found that “medication error” is defined in multiple ways, focusing solely on patient … Illuminating the Naturalistic Decision-Making Processes of Anesthesia Providers To Inform Medication Error-Reducing … Illuminating the Naturalistic Decision-Making Processes of Anesthesia Providers To Inform Medication Error-Reducing

330. The Use of Surgical Simulators to Reduce Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Fried.pdf
     January 01, 2003 - Error reduction and surgical expertise can be achieved through the implementation of a dynamic, simulation-based … Errors in ESS were identified, and each error was classified according to a taxonomy of error types … Quantifiable measures then were defined for each error. … This rigorous process has brought to the project an added emphasis on error reduction prevention as … uniform and comprehensive manner precisely what the errors are and how to avoid them.23 The key to error

331. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - Error traps (i.e., unpredictable situations in which error is highly likely) are another vivid concept … Some, such as understanding human error, come from human physiology and psychology. … Human error. Boston: Cambridge University Press; 1990. 12. Leape LL. Error in medicine. … Error, stress, and teamwork in medicine and aviation: Cross- sectional surveys. … Evaluation of error in medicine: Application of a public health model.

332. Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician’s Office (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Galt.pdf
     April 23, 2004 - Error management Most offices had a formal system in place for reporting an actual error in the employment … site, and indicated they report hazardous situations that could lead to an error. … Error disclosure to patients was the general practice reported by these offices. … exchange of information that could contribute to future error prevention. … must be changed to improve office error-reduction practices.

333. Clinical Inertia and Outpatient Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
     January 01, 2003 - Subsequent actions are also in error, since knowledge of appropriate thresholds fails to cover future … Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel

334. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-slides.pptx
     June 01, 2021 - Human Error. Cambridge: Cambridge University Press; 1990.  … Human Error. Cambridge: Cambridge University Press; 1990.  1. … Human Error. Cambridge: Cambridge University Press; 1990.  1. … Human Error. Cambridge: Cambridge University Press; 1990.  1. … Human Error.

335. Using the AHRQ Hospital Survey on Patient Safety Culture as an Intervention Tool for Regional Clinical Improvement Collaboratives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Adams-Pizarro_109.pdf
     January 08, 2008 - In “Human Error: Models and Management,”7 James Reason describes the attributes 1 of high-reliability … Feedback and communication about error. 3. Frequency of events reported. 4. … Nonpunitive response to error. 7. Organizational learning/continuous improvement. 8. … Provide feedback about reported errors to staff Nonpunitive response to error Implement effective … Human error: models and management. BMJ 2000; 320: 768-770. 8. Marx D.

336. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-ref.html
     September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Committee on Diagnostic Error in Health Care; Board of Health Care Services; Institute of Medicine; The … feedback, learning, and improvement: answering the call of the Institute of Medicine Report on Diagnostic Error

337. Using the AHRQ Pharmacy Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/motzslides.pdf
     June 02, 2025 - 2012 • Annual Aurora Patient Safety Goals include SOPS survey results - Non-punitive response to error … (HOSPITALS) - Communication about error (CLINICS) - Goal = Top quartile (AHRQ comparative database

338. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lipsitz-report.pdf
     January 01, 2024 - Two physicians independently reviewed each TCE to determine if a medical error had occurred. … combined in a third model to identify factors that conferred a higher risk for experiencing a medical error … geriatrician and hospitalist who reached consensus about whether a particular event was a medical error … In 14.7% of all discussions, a medical error was identified. … Furthermore, it suggests that the discharging service and time of day may be associated with risk of error

339. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - An organization must expect error and train staff to recognize and recover. 2. … To facilitate the work involved in decreasing error frequency, Trinity Health needed first to collect … In a culture of blame, the focus is on human error rather than on root causes. … However, too many processes in health care still rely on human perfection to prevent error. … Error in medicine.

340. Prologue—Volume 2—Systems Thinking and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schyve.pdf
     June 02, 2025 - Even today, preventable patient harm is too often associated with error—usually human error—both within … Such error is, in the minds of many, to be met with blame and punishment. … improvement—which provides a much less threatening context than the former reliance on accusations of error … Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel