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381. PRIMARY CARE OFFICE-BASED TEAMS Situation Monitoring
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module5/5_ts_office_sitmon-ig.pptx
     January 20, 2006 - Cross-monitoring is a process of ongoing monitoring of the environment of care to recognize risk or unfolding error … Cross-monitoring is not a way to “spy” on other team members, but a way to provide a safety net or error … prevention/error interruption mechanism for the team, ensuring that mistakes or oversights are caught … The insurer realized their error and covered the mammogram.  … A shared mental model serves as an error reduction strategy, and caregivers who understand the plan monitor

382. 2024 SOPS Hospital Database Report Executive Summary Overview Infographic (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/hospital/2024-hospital-database-report-summary.pdf
     January 01, 2024 - Lowest Scoring Composite Measures Response to Error 64% of respondents reported that staff are treated … Database Results from 2021 to 2024 Communication About Error had t he largest average percent positive

383. Improving Diagnosis: A Vital Patient Safety Frontier | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/vital-patient-safety-frontier.html
     June 01, 2019 - In worst cases, diagnostic error can directly lead to an otherwise preventable death. … Diagnostic error, regardless of its cause, is a serious and complex problem that demands attention. … We are all patients at one time or another, and we are all at risk of experiencing a diagnostic error

384. TeamSTEPPS Implementation: Strategies for Success
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-august2013.pptx
     January 01, 2013 - Improvement from 2007 to 2011 Communication / Openness + 1% + 6.7% +6.8% Feedback and Communication about Error … 11.30% +10.1% Hospital Management Support for Patient Safety + 3% + 8% +12.5% Non-punitive Response to Error … AHRQ Question Improvement Communication Openness 3.3% Feedback and Communication about Error … Hospital Handoffs & Transitions 8.0% Hospital Management Support.. 5.8% Nonpunitive Response to Error

385. Table 1. Overview of studies on the effectiveness of checklists | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxchecklists-table1.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Table 1. … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error

386. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
     April 02, 2020 - Reducing Diagnostic Error: Measurement Considerations. … The challenges in defining and measuring diagnostic error. … The incidence of diagnostic error in medicine. … Minimizing diagnostic error: the importance of follow-up and feedback. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

387. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science-brief1.pdf
     April 02, 2020 - Reducing Diagnostic Error: Measurement Considerations. … The challenges in defining and measuring diagnostic error. … The incidence of diagnostic error in medicine. … Minimizing diagnostic error: the importance of follow-up and feedback. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

388. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 -  To assess the impact of stimulated reporting on reported error/adverse event rates. … Scope: Background: Error Reporting Systems, and Learning from Error Although iatrogenic injury causes … The goals will be to refine error detection and classification schemes so that reports can be used by … However, there was no impact on the serious medication error rate or the preventable ADE rate. … may be defined as the defect in the system that permitted such an error to occur.

389. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.html
     August 01, 2022 - Slide 9 Say: 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 … Forcing functions, checks, and redundancies are some features of systems intended to minimize the risk of error

390. Appendix A. SIDM Competencies To Improve Diagnosis and Suggested Questions for Debriefing Case Studies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/nurse-role-dxsafety-apa.html
     September 01, 2022 - and understand the systems factors that facilitate and contribute to timely, accurate diagnoses and error … Discuss how human factors contribute to diagnostic safety and error by identifying how the work environment … What are some reasons an error could occur related to your work environment? … How and to whom would you report this error [or missed opportunity]?

391. Appendix A. SIDM Competencies To Improve Diagnosis and Suggested Questions for Debriefing Case Studies | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html
     September 01, 2022 - and understand the systems factors that facilitate and contribute to timely, accurate diagnoses and error … Discuss how human factors contribute to diagnostic safety and error by identifying how the work environment … What are some reasons an error could occur related to your work environment? … How and to whom would you report this error [or missed opportunity]?

392. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
     January 01, 2007 - Introduction Although the extent of medical error has been well characterized among general medicine … Since physicians are doing the reporting, this would mean less opportunity for them to notice an error … Second, the level of clinical responsibilities and the corresponding available time to devote to error … Finding and fixing medical error: Opportunities for clinicians. … Error in medicine. JAMA 1994; 272: 1851-1857. 12 Chaudhry SI, Olofinboba KA, Krumholz HM.

393. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
     June 15, 2003 - limitations of current reporting systems and realities constraining their use inhibit widespread error … Safety infrastructure Error reporting systems and associated information sharing and problem- solving … , ongoing quality improvement programs, and internal reporting systems for complying with multiple error … Some hospitals also keep separate, customized medication error databases, while other hospitals use … Finally, there is a high degree of informal error reporting that is not captured by any system.

394. Catheter Care and Maintenance Quiz | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/quiz.html
     March 01, 2017 - Determine the catheter care error. … Determine the catheter care error.

395. TeamSTEPPS for Diagnosis Improvement: Knowledge Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/dxsafety-knowledge-assessment.pdf
     February 01, 2022 - TeamSTEPPS To Improve Diagnosis uses the National Academy of Medicine definition of diagnostic error … Using this definition, which of the following may be considered a diagnostic error? a. … Causes of diagnostic error may include: a. Poor clinical reasoning. b. … Diagnostic error is: a. Common, harmful. b. Costly and often preventable. c. … Is a tool designed for individuals who have made a diagnostic error. a.

396. TeamSTEPPS for Diagnosis Improvement: Knowledge Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-knowledge-assessment.pdf
     February 01, 2022 - TeamSTEPPS To Improve Diagnosis uses the National Academy of Medicine definition of diagnostic error … Using this definition, which of the following may be considered a diagnostic error? a. … Causes of diagnostic error may include: a. Poor clinical reasoning. b. … Diagnostic error is: a. Common, harmful. b. Costly and often preventable. c. … Is a tool designed for individuals who have made a diagnostic error. a.

397. Special Considerations for Measurement of Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2.html
     June 01, 2020 - The recent NASEM report defines diagnostic error as the “failure to establish an accurate and timely … longitudinal continuum of patient care, as well as pragmatic tools to help measure and address diagnostic error … evaluated in research settings, few HCOs take a systematic approach to measure or monitor diagnostic error … Use of a single method to identify diagnostic error, such as manual chart reviews or voluntary reporting … Table 1 describes various data sources and strategies that could enable measurement of diagnostic error

398. Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship.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

399. Final Progress Report: Systems Approach for Improving Region-Wide Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
     January 01, 2024 - Error reduction in organizations involves exploration and evaluation of multiple interrelated systems … Adverse Drug Events (ADEs), which can result from a medication error, occur at a rate of 2.4% to 4.6% … The purpose of MedMARx is to allow hospitals to report, track, and share medication error data in a … on Medication Error Reporting and Prevention (NCCMERP). … Perceived Barriers in Using a Region-Wide Medication Error Reporting System.

400. Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hannah_23.pdf
     February 24, 2008 - • Nonpunitive response to error. … • Feedback & communication about error. … Error in medicine. JAMA 1994; 272: 1851-1857. 5. Leape LL. Preventing adverse drug events. … Promoting patient safety by preventing medical error. JAMA 1998; 280: 1444-1447. 11. … Error, stress, and teamwork in medicine and aviation: Cross sectional surveys.