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341. 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.

342. 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

343. 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

344. 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

345. 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.

346. 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.

347. 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.

348. Data Reveal Uneven Impact of COVID-19 on Urban, Rural Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/913.html
     May 01, 2024 - Diagnostic Error in Mental Healthcare Common but Not Well Defined . … Diagnostic Error in Mental Healthcare Common but Not Well Defined Diagnostic error is well understood … They found that few studies used clear definitions or frameworks for understanding diagnostic error in

349. 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.

350. 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.

351. 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

352. 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

353. 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

354. 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.

355. 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

356. Sustainability: Learning From Defects: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
     December 01, 2017 - ” — James Reason, Human Error, 1990 1 Slide 8: AHRQ Safety Program for Surgery—Sustainability … Slide 18: Rank Order of Error Reduction Strategies 5 Image: Chart captioned "Strength of Interventions … Human Error: models and management. BMJ 2000;320:768-70. PMID: 10720363. … Selecting the best error-prevention "tools" for the job. 2006. 

357. Info FAQs | Agency for Healthcare Research and Quality
     www.ahrq.gov/faqs/index.html?page=4
     June 12, 2025 - Feedback & communication about error. Frequency of events reported. … Nonpunitive response to error. Organizational learning—continuous improvement. … Six of the survey dimensions (Communication Openness, Communication About Error, Organizational Learning … The dimensions in the medical office survey are: Communication about error.

358. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
     January 01, 2005 - and Quality), multidisciplinary teams have been assembled to identify and address the sources of error … Advances in Patient Safety: Vol. 2 390 mistake and potential consequences of the error. … Error reduction as a systems problem. In: Bogner MS, editor. Human error in medicine. … Human error: their causes and reduction. In: Bogner MS, editor. Human error in medicine. … The use of failure mode effect and criticality analysis in a medication error subcommittee.

359. Tool 5 (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/postdischarge-doc.html
     March 01, 2025 - _____________________ ___ Intentional nonadherence ___ Inadvertent nonadherence ___ System/provider error … _____________________ ___ Intentional nonadherence ___ Inadvertent nonadherence ___ System/provider error … _____________________ ___ Intentional nonadherence ___ Inadvertent nonadherence ___ System/provider error

360. Postdiscalldoc (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdiscalldoc.docx
     June 02, 2025 - effects): Medicine 1: Problem: Intentional nonadherence Inadvertent nonadherence System/provider error … back Other: Medicine 2: Problem: Intentional nonadherence Inadvertent nonadherence System/provider error … back Other: Medicine 3: Problem: Intentional nonadherence Inadvertent nonadherence System/provider error