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3481. Patient Safety Issues in Primary Care Are Real | Agency for Healthcare Research and Quality
      www.ahrq.gov/data/infographics/patient-safety-issues.html
      August 01, 2018 - Patient Safety Issues in Primary Care Are Real Patient Safety Issues in Primary Care Are Real (PDF, 324 KB) Source: Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families

3482. 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.

3483. Making Healthcare Safer Practices: 13. Alarm Fatigue (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/alarm-fatigue-1.pdf
      March 01, 2020 - Making Healthcare Safer Practices: 13. Alarm Fatigue Alarm Fatigue 13-1 13. Alarm Fatigue Authors: Meghan Woo, Sc.D., and Olivia Bacon Reviewer: Ann Gaffey, R.N., M.S.N., CPHRM, DFASHRM Introduction Alarm fatigue occurs when clinicians experience high exposure to medical device alarms, causing alarm desensitiz…

3484. Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/confidreportguide_0.pdf
      March 01, 2016 - procedure) Safe care measures Example: Computerized physician order entry with medication error … A correction feature or protocol that allows physicians to note where data appear to be in error not … reports allow physicians to drill down to patient-level data and note where data appear to be in error

3485. Accurate ADHD Diagnosis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-088-fullreport.pdf
      January 05, 2017 - Accurate ADHD Diagnosis Accurate ADHD Diagnosis Section 1. Basic Measure Information 1.A. Measure Name Accurate ADHD Diagnosis 1.B. Measure Number 0088 1.C. Measure Description Please provide a non-technical description of the measure that conveys what it measures to a broad audience. Percentage of patien…

3486. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/25702-Lipsitz-draft-1.pdf
      August 31, 2022 - 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

3487. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/25702-Lipsitz-report.pdf
      August 31, 2022 - 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

3488. Improving Patient Safety Systems for Limited English Proficiency Patients
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pptx
      January 01, 2011 - of bilingual hospital staff as ad hoc interpreters for LEP patients, despite greater likelihood of error … populations to better understand root causes and high-risk scenarios Develop strategies for improvement and error

3489. Improving Patient Safety Systems for Limited English Proficiency Patients: A Guide for Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pdf
      January 01, 2011 - of bilingual hospital staff as ad hoc interpreters for LEP patients, despite greater likelihood of error … to better understand root causes and high-risk scenarios  Develop strategies for improvement and error

3490. Module 20 Appendix B | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/pf-handbook/mod20-appendix-b.html
      March 01, 2022 - Practice Facilitation Handbook Module 20 Appendix B Previous Page Next Page Table of Contents Practice Facilitation Handbook Module 1. Practice Facilitation as a Resource for Practice Improvement Module 1 Trainer’s Guide: Practice Facilitation as a Resource for Practice Improve…

3491. Module 10 Appendix | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/pf-handbook/mod10-appendix.html
      March 01, 2022 - Practice Facilitation Handbook Module 10 Appendix Previous Page Next Page Table of Contents Practice Facilitation Handbook Module 1. Practice Facilitation as a Resource for Practice Improvement Module 1 Trainer’s Guide: Practice Facilitation as a Resource for Practice Improveme…

3492. Creating Capacity for Improvement in Primary Care, No. 1 (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/pcmhqi1.pdf
      April 01, 2013 - Creating Capacity for Improvement in Primary Care, No. 1 1 Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Decisionmaker Brief: Primary Care Quality Improvement No. 1 Creating Capacity for Improvement in Primary Care: The Case for Developing a Quality Improveme…

3493. Statistical Process Control: Possible Uses to Monitor and Evaluate Patient-Centered Medical Home Models (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/statistical-process-control.pdf
      March 01, 2013 - Statistical Process Control: Possible Uses to Monitor and Evaluate Patient-Centered Medical Home Models c Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov The PCM Portfolio graphic element is intended to be closely aligned with AHRQ's overall brand, while also Ch…

3494. The Logic Model: The Foundation to Implement, Study, and Refine Patient-Centered Medical Home Models (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/logic-model-brief.pdf
      March 01, 2013 - The Logic Model: The Foundation to Implement, Study, and Refine Patient-Centered Medical Home Models c Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov The PCM Portfolio graphic element is intended to be closely aligned with AHRQ's overall brand, while also Chron…

3495. 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

3496. 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
      May 12, 2014 - 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

3497. Improving Patient Safety Systems for Limited-English-Proficient (LEP) Patients: A Guide for Hospitals | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
      December 01, 2012 - of bilingual hospital staff as ad hoc interpreters for LEP patients, despite greater likelihood of error … Develop strategies for improvement and error prevention.

3498. Advances in Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/resources/advances/index.html
      October 01, 2014 - 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 File … Hargarten Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative … Weinger Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? … Hilborne Standardizing Medication Error Event Reporting in the U.S.

3499. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
      May 05, 2008 - On error management: Lessons from aviation. Br Med J 2000; 320: 781-785. 4. Reason J. … Human error. Cambridge, UK: Cambridge University Press; 1990. 6. Hagland M. … Operating at the sharp end: The complexity of human error. In: Bogner M, ed. … Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum; 1994. 33. Reason J. … Safety in the operating theatre – Part 2: Human error and organisational failure.

3500. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
      www.ahrq.gov/health-literacy/professional-training/lepguide/app-f.html
      September 01, 2020 - to better understand root causes and high-risk scenarios, and develop strategies for improvement and error