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341. 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

342. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
     March 01, 2017 - Can you identify examples of human error in your unit or facility? … Slide 19: Managing Error and Risk 1 Say: To improve outcomes, human error, at-risk behavior, and … 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 team members who have committed a human error and to ensure

343. Background | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship3.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

344. 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

345. 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

346. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
     January 25, 2008 - Medication error B. Adverse drug reaction (not a medication error) C. … Error related to procedure, treatment, and/or test F. … Distinguishing acute from chronic conditions—diagnoses with a single opportunity for error vs. … diagnoses with multiple opportunities for error—can be useful. … Medical Care Availability and Reduction of Error (MCARE) Act.

347. 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

348. Fallpxtool3J (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3j.docx
     January 29, 2013 - Short Portable Mental Status Questionnaire Question Response Error? … *A mistake on ANY part of this question should be scored as an error. … 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment *One more error … One less error is allowed if the patient has had education beyond the high school level.

349. Improving Diagnosis in the Context of Rurality | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-rural-healthcare2.html
     October 01, 2024 - Each year, approximately 12 million U.S. adults experience a diagnostic error, leading to as many as

350. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses6.html
     August 01, 2022 - What interventions could reduce diagnostic error in emergency departments? … Understanding the social in diagnosis and error: a family of theories known as situativity to better … inform diagnosis and error. … Interdisciplinary communication: an uncharted source of medical error? … Diagnostic error in medicine: analysis of 583 physician-reported errors.

351. AHRQ Quality Indicators Boost Kentucky's Public Reporting Efforts | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cdom0905.html
     October 01, 2014 - given prevention quality indicator: Green: If an area's risk-adjusted rate (considering a margin of error … Yellow: If an area's risk-adjusted rate (considering a margin of error) is comparable to the national … Red: If an area's risk-adjusted rate (considering a margin of error) is higher than the national average

352. Using Just Culture to Improve Hospital Survey on Patient Safety Culture Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-transcript.html
     January 01, 2017 - to feature Celeste Mayer, who will talk about her experiences improving the Nonpunitive Response to Error … for this webinar, Nonpunitive Response to Error. … So, what is Nonpunitive Response to Error? What does it really consist of? … to what we call Response to Error, to include more Just Culture principles in the survey items. … There is a section for Nonpunitive Response to Error.

353. Just Culture Webcast November 2016 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-transcript-508-compliant.pdf
     June 01, 2017 - to feature Celeste Mayer, who will talk about her experiences improving the Nonpunitive Response to Error … for this webinar, Nonpunitive Response to Error. … So, what is Nonpunitive Response to Error? What does it really consist of? … to what we call Response to Error, to include more Just Culture principles in the survey items. … There is a section for Nonpunitive Response to Error.

354. 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

355. Research Summit: Improving Diagnosis in Health Care: Agenda | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-agenda.html
     August 01, 2017 - MM/MBA Stanford University Breakout 1 (morning): Use of Data and Measurement in Reducing Error … MM/MBA Stanford University Breakout 2 (afternoon): Use of Data and Measurement in Reducing Error … Lucy Savitz, PhD, MBA Intermountain Healthcare Helen Haskell, MA Mothers Against Medical Error

356. 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

357. Gap Analysis Facilitator's Guide: Appendix E | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.html
     August 01, 2022 - While restitution for patients and families affected by medical error is essential, the standard process … frustration and anger for patients and can diminish the opportunity for hospitals to learn and improve from error

358. Spanish Community Pharmacy Survey on Patient Safety Culture Items and Dimensions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/toolkit/pharmcomps_span.pdf
     April 01, 2014 - Cuando ocurre un error, tratamos de averiguar los problemas en los procesos que dieron lugar al error … Cuando un error sigue ocurriendo, cambiamos la manera en que se trabaja. C10. … Cuando el paciente recibe un medicamento con algún error que podría causarle daño al paciente pero no … Cuando el paciente recibe un medicamento con algún error que no tiene la posibilidad de causar daño, … Cuando un error que podría haber causado daño al paciente se corrige ANTES de que el medicamento salga

359. Spanish Community Pharmacy Survey on Patient Safety Culture Items and Dimensions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/measures-spanish.pdf
     April 01, 2014 - Cuando ocurre un error, tratamos de averiguar los problemas en los procesos que dieron lugar al error … Cuando un error sigue ocurriendo, cambiamos la manera en que se trabaja. C10. … Cuando el paciente recibe un medicamento con algún error que podría causarle daño al paciente pero no … Cuando el paciente recibe un medicamento con algún error que no tiene la posibilidad de causar daño, … Cuando un error que podría haber causado daño al paciente se corrige ANTES de que el medicamento salga

360. Diagnostic Safety Grants Awarded in FY 2019 | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/grants-2019.html
     March 01, 2024 - machine learning models that can be used to retrospectively identify patients in whom a diagnostic error