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361. Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
     April 01, 2021 - system for hospitalized patients, and Project 2 addressed the common but understudied area of diagnostic error … Bridging the gap between systems-based and cognitive contributions to diagnostic error . … Bridging the gap between systems-based and cognitive contributions to diagnostic error .

362. 2018 Hospital SOPS Database Report Executive Summary Infograpic (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsrptexecsum_0.pdf
     March 01, 2018 - change Areas of potential for improvement for most hospitals 470/o Nonpunitive Response to Error … composites 35% of hospitals Increased by 5 percentage points or more on Non positive Response to Error

363. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - If the focus is on the process and the system factors that facilitated the error, the process can be … adjusted to minimize human error, resulting in fewer opportunities to err again. … (Table 1) Table 1: Behavior Classification Normal Error (Human Error) At-risk Behavior … If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … questions such as "Why was there human error?

364. Understanding SOPS Surveys: A Primer for New users -Gray (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/2-SOPS_101_Webcast_2020-Gray.pdf
     January 01, 2020 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management … • Diagnostic Safety (Medical Office)—Spring 2021 ► Assist in identifying processes and sources of error

365. Table of Contents: Volume 1. Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
     January 01, 2025 - Improving Error Reporting in Ambulatory Pediatrics with a Team Approach Daniel R. … Taxonomies and Measurement Development of a Comprehensive Medical Error Ontology Pallavi Mokkarala … A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care Ranjit Singh … xi Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy … Error Producing Conditions in the Intensive Care Unit Frank A. Drews, Adrian Musters, Matthew H.

366. Table of Contents: Volume 4. Technology and Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/TableofContents_Vol4.pdf
     January 01, 2025 - Improving Error Reporting in Ambulatory Pediatrics with a Team Approach Daniel R. … Taxonomies and Measurement Development of a Comprehensive Medical Error Ontology Pallavi Mokkarala, … A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care Ranjit Singh … xiii Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy … Error Producing Conditions in the Intensive Care Unit Frank A. Drews, Adrian Musters, Matthew H.

367. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence1.html
     April 01, 2025 - Diagnostic error is a major source of preventable harm and increased costs across healthcare settings … If we are to achieve diagnostic excellence and the goal of zero preventable harm from diagnostic error

368. 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.

369. 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/hospitalresourcelist.pdf
     January 01, 2019 - Feedback and Communication About Error .............................................................. … Feedback and Communication About Error 1. … Missed nursing care is a subset of the category known as error of omission. … Nonpunitive Response to Error 1. … Feedback and Communication About Error Composite 6. Communication Openness Composite 7.

370. TeamSTEPPS Learning Benchmarks (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
     June 02, 2025 - doctor on the team make a misstatement about a sick patient, a comment that could result in a medical error … The following are human factor problems that research has identified as contributing to medical error … the right information 4 E • Two-Challenge rule • CUS (Concerned-Uncomfortable-Patient Safety) • Error … the line; resolve the confusion • Respect the input • Team dynamic • Focus on the safety, not the error … part of the team 10 B • Debrief-the word more than the concept • Deals with issues of blame and error

371. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appa.html
     August 01, 2022 - Managing the risks of malpractice and error disclosure. … It contains four scales: error disclosure general culture, error disclosure trust culture, safety, and … teamwork, and also includes items on “intent to disclose” a hypothetical error. … For those having received training, minor error disclosure culture, serious error disclosure culture, … Error disclosure: A new domain for assessing safety culture.

372. Diagnostic Terminology: Challenges and Opportunities | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology10.html
     April 01, 2025 - Humans as Problems or Assets  The concept of diagnostic error and Safety-I imply that humans are the … Recognize that the language of diagnosis, assorted descriptions for diagnostic error, and various approaches

373. AHRQ's Patient Safety Culture Survey Targets Improvement at Cincinnati Children's Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0605.html
     October 01, 2014 - The lowest areas were for "non-punitive response to error" and "hospital handoffs and transitions." … "The low score for non-punitive response to error was surprising to us," Dresselhaus admits, "because

374. What Is Patient Safety Culture? | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/about/patient-safety-culture.html
     June 01, 2024 - The areas of patient safety culture assessed by the AHRQ SOPS surveys include: Communication About Error … Response to Error. Staffing. Supervisor and Management Support for Patient Safety. Teamwork.

375. Facilitator’s Implementation Roadmap: TeamSTEPPS® Diagnosis Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-facilitator-roadmap.pdf
     February 01, 2022 - Use the Course Infographic to provide current information pertaining to diagnostic error and its impact … Sharing data on the frequency of diagnostic error in both ambulatory and acute care settings and their

376. Measures of Cognitive Load | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load4.html
     May 01, 2024 - To better design studies that can causally link unsafe levels of cognitive load with diagnostic error … These tools have commonly been used to study cognitive load and working memory, including recall, error … Although this type of error would be considered a “near-miss” since it never reaches the patient, research … however, it will be important to understand the impact of this technology on cognitive load, diagnostic error

377. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
     July 05, 2023 - Thus, capitation and payer integration lie to the left of direct error penalties in . … What is Diagnostic Error?: Improvediagnosis.org. diagnostic-error/ [Accessed 26 Jul 2022]. 6. … Payment innovations to improve diagnostic accuracy and reduce diagnostic error. … Interventions targeted at reducing diagnostic error: systematic review. … Diagnostic error inmedicine: analysis of 583 physician-reported errors.

378. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
     June 03, 2008 - conference (M&MC) is a traditional forum that provides clinicians with an opportunity to discuss medical error … .7 When error is discussed in the M&MC, the focus is often on an unexpected adverse outcome instead … of events related to processes of care that might have contributed to the error.5 Physician trainees … attending the M&MC often feel that the purpose of the discussion is to assign blame for an error rather … The morbidity and mortality conference: The delicate nature of learning from error.

379. Postdiscalldoc (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/red-toolkit/postdiscalldoc.pdf
     June 02, 2025 - _______________________  Intentional nonadherence  Inadvertent nonadherence  System/provider error … _______________________  Intentional nonadherence  Inadvertent nonadherence  System/provider error … _______________________  Intentional nonadherence  Inadvertent nonadherence  System/provider error

380. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
     December 01, 2003 - encourages key decisionmakers to consider systems and organizational issues in the management of error … David Marx, an international consultant in human error management, explains how anxiety inhibits most … Leape argues, “The single greatest impediment to error prevention is that we punish people for making … more than 25 years, Professor Reason’s principal area of research has been the management of human error … Managing maintenance error: a practical guide.