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401. SOPS Program Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/sops-program-brief-2024.pdf
     January 01, 2024 - surveys can be used to assess many areas of patient safety culture, including:  Communication About Error …  Response to Error.  Staffing.  Supervisor and Management Support for Patient Safety. … Conduct a review of the literature on patient safety, safety culture, medical error, event reporting

402. 2018 Hospital Survey on Patient Safety Culture Part I (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport.pdf
     March 01, 2018 - Nonpunitive Response to Error Staff feel like their mistakes are held against them. … Feedback & Communication About Error 69% 7.81% 38% 59% 64% 69% 73% 79% 90% 6. … Feedback & Communication About Error 69% 68% 1% 16% -40% 4% -4% 6. … Feedback & Communication About Error C1 1. … Nonpunitive Response to Error A8R 1.

403. 2018 Hospital Survey on Patient Safety Culture Part I (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2018hospitalsopsreport-rev0921.pdf
     March 01, 2018 - Nonpunitive Response to Error Staff feel like their mistakes are held against them. … Feedback & Communication About Error 69% 7.81% 38% 59% 64% 69% 73% 79% 90% 6. … Feedback & Communication About Error 69% 68% 1% 16% -40% 4% -4% 6. … Feedback & Communication About Error C1 1. … Nonpunitive Response to Error A8R 1.

404. Improving Patient Safety by Engaging Patients and Families (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
     April 30, 2025 - Patient and family engagement efforts include involving patients and families in medical error reporting … They also submitted a scientific abstract to the annual SIDM meeting describing the diagnostic error … Economic evaluation identified some effect of error status on subsequent healthcare utilization. … ++Talking+with+patients+and+families+about+medical+error:+A+guide+for+education+and+practice. … ++Talking+with+patients+and+families+about+medical+error:+A+guide+for+education+and+practice.

405. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-slides.html
     March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1 Human Error: Inadvertently completing the wrong … Slide 19: Managing Error and Risk 1 Human Error At-Risk Behavior Reckless Behavior

406. Research Summit: Improving Diagnosis in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/brady-summit2016-plenary.pdf
     September 28, 2016 - Studies in Primary Care • Determine types of diseases missed and processes involved in confirmed Dx error … after initial primary care visit) Singh et al., 2013 • Conduct survey of physicians for recall of Dx error … Acrobat Accessibility Report Accessibility Report Filename: Brady AHRQ Dx Error

407. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
     April 09, 2004 - program was created by the legislature to capture preventable events caused by human or mechanical error … As a result of the IOM report, several actions occurred to bring adverse event/medical error reporting … for improving health care quality and funded demonstration projects to study adverse event/medical error … The medication error subcommittee develops medication error reporting categories and the medication … Discussion Current proposals for voluntary adverse event/medical error reporting systems build on

408. Strategies To Promote Psychological Safety and Organizational Safety Culture Related to Diagnosis | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-4.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 … Professionals may develop their own system to surveil for error, although consistent and reliable feedback

409. Making Healthcare Safer Practices: 12. Infusion Pumps (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/infusion-pumps-1.pdf
     March 01, 2020 - Many newer infusion pumps are equipped with predetermined clinical guidelines, dose error reduction … Infusion device standardisation and dose error reduction software. … Nearly 48% (47.9%) of infusions had at least one procedural or documentation error. … Error rates were similar. … Infusion rate errors were the leading type of serious medication error.

410. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/summary.html
     August 01, 2022 - had participated in disclosure and apology training had significantly more positive attitudes about error … disclosure, and they perceived disclosure of a medical error as less damaging to patient and peer trust … A new 51-item survey was developed to examine the relationship between patient safety culture and error … This project also involved developing, implementing, and evaluating error disclosure through a coordinated … guidelines for outpatient primary care practice staff on how to communicate with patients after an error

411. New AHRQ SOPS® Workplace Safety Supplemental Item Set for Nursing Homes - Caren Ginsberg, Ph.D. (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/nh-workplace-safety-ginsberg.pdf
     January 01, 2015 - Center 2015 12 Areas of Patient Safety Culture Assessed Across SOPS Surveys • Communication About Error … Organizational Learning – Continuous Improvement • Overall Rating on Patient Safety • Response to Error

412. Final Progress Report: Shared Decision Making in Surgery To Improve Patient Safety and Reduce Liability (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
     January 01, 2024 - Resource consumption for patient complaints was similar to medical error resolution. … the following data were abstracted: medical service and procedure associated with the complaint or error … Mean staff time per complaint file (10.7 hours) was double that for error files (5.8 hours, p<0.01). … In contrast, most error files (62%) involved some compensation for treatment compared to the minority … The size of compensation was higher in error files (mean $4,302) compared to complaints (mean $702,

413. References (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/14-diagnostic-safety-toolkit-references.pdf
     November 24, 2020 - Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; … Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among … The patient is in: patient involvement strategies for diagnostic error mitigation. … The incidence of diagnostic error in medicine.

414. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - This error was detected without harm to the participant. … This medication error was detected by a staff nurse prior to drug administration. … Error in medicine. JAMA 1994; 272(23):1851–7. 21. Steinbrook R. … Human error. New York: Cambridge University Press; 1990. 34. Barach P, Small SD. … Human error: models and management. BMJ 2000;320(7237):768–70. 42. Weeks WB, Bagian JP.

415. An Overview of the SOPS® Surveys for New Users - Kirchner (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/3-sops101-webcast-2023-kirchner.pdf
     January 01, 2023 - Center 2015 12 Areas of Patient Safety Culture Assessed Across SOPS Surveys • Communication About Error … Organizational Learning – Continuous Improvement • Overall Rating on Patient Safety • Response to Error

416. Voluntary Hospital Coalitions to Promote Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rask.pdf
     January 01, 2004 - Advances in Patient Safety: Vol. 3 498 alerts are then produced and distributed so that an error … Hospitals will be able to access their own data internally so that error reports can be used to guide … Another awardee (a 300+ bed regional hospital) developed the Systematic Assessment of Flow and Error … Among participating hospitals, 105 (73 percent) reported a decrease in the targeted medication error … Only 14 hospitals (7 percent) were unable to provide a measurable outcome from their medication error

417. CHIPRA 133: Section 2 Technical Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-133-section-2-tech-specs.pdf
     January 01, 2011 - Multiply the standard error by 1.96. c. Subtract that value from the measured proportion. … Multiply the standard error by 1.96. c. Subtract that value from the measured proportion. … Multiply the standard error by 1.96. c. Subtract that value from the measured proportion. … Multiply the standard error by 1.96. c. Subtract that value from the measured proportion. … Multiply the standard error by 1.96. c. Subtract that value from the measured proportion.

418. Final Progress Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
     January 01, 2024 - and Significance Intervention 1: Patient Counseling The effectiveness of patient counseling as an error … Both offer qualitative information about risk and error, but neither helps quantify the level of risk … The tool, High-Alert Medication Modeling and Error-Reduction Scorecards™ (HAMMERS™), offers community … An error or potential error was detected during five of the counseling sessions in the comparison-group … Bar coding: working toward error-free pharmacy. Pharmacy Times Sept 1, 2003.

419. Co-producing a Diagnosis
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/09-diagnostic-safety-practice-orientation.pptx
     November 24, 2020 - 2021 1 Diagnostic Errors Are a Big Challenge Nearly every person will experience a diagnostic error … Diagnostic error is the leading patient safety challenge in the United States. … We define diagnostic error as “the failure to (a) establish and accurate and timely explanation of the … The patient is in: patient involvement strategies for diagnostic error mitigation. … The incidence of diagnostic error in medicine.

420. Creating a Curriculum for Training Health Profession Faculty Leaders (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Mitchell.pdf
     March 31, 2004 - Basics, Developing Academic Leadership, Improving the Culture of Practice, Changing the Response to Error … Promoting patient safety and preventing medical error in emergency departments. … Multidisciplinary approaches to reducing error and risk in a patient care setting. … Human factors engineering is the basis for a practical error-in-medicine curriculum. … Importance of human factors engineering in error-and-medicine education.