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321. 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

322. 1. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-current-state1.html
     January 01, 2024 - care. 1-9 For example, an estimated 5 percent of the U.S. adult population experiences a diagnostic error … setting every year, 1 and approximately 0.7 percent of inpatients experience harm from a diagnostic error

323. 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.

324. 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.

325. University of Pittsburgh Uses AHRQ's Patient Safety Culture Survey to Help Improve Nursing Home Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0702.html
     October 01, 2014 - to the AHRQ survey when I was preparing to launch a survey to understand the barriers to medication error … patient safety culture data in nursing homes before we implemented a new system to increase medication error … These significant differences were reported in nonpunitive response to error, teamwork within units,

326. 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.

327. 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.

328. 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.

329. 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.

330. 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

331. AHRQ Issue Brief Outlines Competencies Needed To Improve Diagnostic Skills in Health Professions Education | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/806.html
     March 01, 2022 - Most Patients Who Experienced Diagnostic Error Cited Poor Communication With Health Providers . … Most Patients Who Experienced Diagnostic Error Cited Poor Communication With Health Providers Patients … with limited health literacy or low socioeconomic status who experienced a diagnostic error were most … Researchers surveyed nearly 600 people who reported experiencing a medical error caused by a delayed,

332. 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.

333. 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.

334. S2: Using EHR-Based Simulations to Reduce Diagnostic Errors in Ambulatory Care Settings | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/spotlight-s2-gold-ratwani.html
     May 01, 2024 - will use a combination of administrative and claims data to identify diagnoses at risk for diagnostic error

335. (“Apply CUSP” cover slide with CUSP Toolkit logo)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/applycusp.pptx
     August 18, 2011 - staff members who hold themselves accountable 5 5 6 Understanding Risk and Human Behavior1 Human Error … Behavior: Choosing to consciously disregard a substantial and unjustifiable risk 6 Managing Error … and Risk1 7 Human Error Product of our current system design and behavioral choices Manage through changes … communication Identify barriers to communication Describe the connections between communication and medical error

336. Facapplycusp (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
     September 04, 2012 - · 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

337. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-references.html
     June 01, 2023 - Families as partners in hospital error and adverse event surveillance. … 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.

338. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-references.html
     June 01, 2023 - Families as partners in hospital error and adverse event surveillance. … 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.

339. 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 10, 2021 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management

340. 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
     January 21, 2022 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management