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341. 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. 

342. 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.

343. 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

344. 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.

345. Chapter 2. Electronic Searchable Catalog | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program2.html
     April 01, 2018 - Clinical area— the medical specialty related to the article, including in which field the case/error … Error types— classification of error(s) in order to identify root cause(s) and offer solution(s). … Data Entry The data entry process was designed to minimize error in abstraction through a series of … To reduce the possibility of error and facilitate use of the query tool, there are only two write-in … , and Root Cause Analysis will also be selected because they are specific examples of Error Analysis.

346. Tool 5 (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/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

347. 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

348. 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

349. Organizations and Diagnostic Performance: How to End Up with ‘Fewer Misses & More Hits’ that Mean Something to Patients and Their Families (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/mcdonald-summit2016-breakout.pdf
     June 02, 2025 - reporting (ERR) of images and lab results and for EHRs with office problems that could lead to diagnostic error … #2: FOR KNOWLEDGE: Developmental and Evaluative Research within Organizations (H4-6)  Articulate dx error … Model Acrobat Accessibility Report Accessibility Report Filename: AHRQ Dx Error

350. Surveys on Patient Safety Culture (SOPS) Hospital 2.0 Survey: 2024 User Database Report Part II (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/hospital/2024-hospital-database-report-appendix.pdf
     January 01, 2024 - Response to Error 62% 67% 62% 65% 64% 10. … Response to Error 60% 66% 66% 58% 10. … Response to Error 65% 63% 65% 67% 10. … Communication About Error 74% 81% 6. … Response to Error 63% 69% 10.

351. Final Progress Report: NPSF Joint Medical-Legal Conference at SMU (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/nance-report.pdf
     January 01, 2025 - fiduciary responsibility, to be fully, completely, promptly, and honestly informed when a medical error … the act of informing a patient and/or family of the fact of an injury resulting from a mistake or error … Every patient who has been apologized to and fully informed about the details of a medical error that … The CEO of the hospital within 24 hours went to the family, fully disclosed and discussed the error … I listen to the mediator, and every time he says, now this is an egregious error...it’s a big error

352. Final Progress Report: Patient Safety and the Primary Care Testing Process (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/elder-report.pdf
     January 01, 2025 - • Secondary analysis of 600 error reports and transcripts from 18 focus groups from the AAFP DCERPS … Human factors classifications of Risk and Error that produce breaks in quality and safety Safe, … Nurses' perceptions of error communication and reporting in the intensive care unit. … What do family physicians consider an error? … Stretching the search for the 'why' of error: The Systems Approach.

353. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-version-2-resource-list.pdf
     December 01, 2024 - Response to Error, #2. Composite Measure 3. Teamwork 1. … Communication About Error 1. … Response to Error 1. … Missed nursing care is a subset of the category known as error of omission. … Communication About Error Composite Measure 8. Response to Error Composite Measure 9.

354. Consumer Decision Points: Using Online Reports to Gauge Quality of Physician Performance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20110511/patrick-mccabe.pdf
     June 02, 2025 - . – Significantly bad experiences with physician error in the past. … serious condition – MS, Cancer Big Problem with MD • Misdiagnosis or no diagnosis • Medication error

355. Consumer Decision Points: Using Online Reports to Gauge Quality of Physician Performance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/talkingquality/resources/podcasts_webinars/Patrick_McCabe.pdf
     June 02, 2025 - . – Significantly bad experiences with physician error in the past. … serious condition – MS, Cancer Big Problem with MD • Misdiagnosis or no diagnosis • Medication error

356. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/refs.html
     May 01, 2016 - The Public's Views on Medical Error in Massachusetts, Commissioned by the Betsy Lehman Center for Patient … Safety and Medical Error Reduction. … Predictors of chemotherapy patients' intentions to engage in medical error prevention. … Brief report: Hospitalized patients' attitudes about and participation in error prevention.

357. Advances in Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances/index.html
     July 01, 2022 - Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff Organizational Climate, Stress, and Error … Grems, Elizabeth Sloan The Impact of a Patient Safety Program on Medical Error Reporting (   PDF , … Dittus The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence … Weinger Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? … Hilborne Standardizing Medication Error Event Reporting in the U.S.

358. Environmental Scan of Patient Safety Education and Training Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
     June 01, 2013 -  Error types—classification of error(s) in order to identify root cause(s) and offer solution(s … Data Entry The data entry process was designed to minimize error in abstraction through a series of … To reduce the possibility of error and facilitate use of the query tool, there are only two write-in … , and Root Cause Analysis will also be selected because they are specific examples of Error Analysis … Reducing Medical Error Reducing Patient Injuries Safer Patients Teach Patient Safety Root

359. Module 7: Putting It All Together
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module7-all-together.pptx
     January 01, 2008 - to complete this module: 45 minutes (19 slides) 1 Slide Module 7 Objectives Summarize diagnostic error … After completing this module, participants will be able to: Summarize diagnostic error and its importance … can be realized with the successful use of the TeamSTEPPS tools and strategies. 2 Slide Diagnostic Error … Diagnostic error is a patient safety issue. … Every member of the team can help prevent a diagnostic error.

360. Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast - Bakdash (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-sops-teamstepps-webcast-bakdash.pdf
     January 01, 2022 - and Work Pace (4 items) • Organizational learning – Continuous Improvement (3 items) • Response to Error … • Supervisor, Manager or Clinical Leader Support for Patient Safety (3 items) • Communication About Error