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401. 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.

402. Cognitive Load Theory and Its Impact on Diagnostic Accuracy: Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load-theory.pdf
     May 01, 2024 - the Institute of Medicine in 1999, was one of the first publications to bring the issue of medical error … In addition, diagnostic error may result in serious harm to more than 500,000 Americans each year across … often takes place after the error has occurred. … Burden of serious harms from diagnostic error in the USA. … Diagnostic error in internal medicine.

403. Georgia Hospitals Use AHRQ Blood Thinner DVD to Help Reduce Errors, Improve Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0903.html
     October 01, 2014 - to hide a mistake that did not result in actual harm; an equally unconvincing attempt to dismiss an error … A discussion ensues, moderated by Banja, about whether a clinician who admits error risks lawsuits and

404. Final Progress Report: Workshop on Consumer Engagement in Selected Patient Safety Topics (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/hatlie-report.pdf
     January 01, 2024 - Effectively responding when error occurs, and engaging patients in organizational learning from such … Prioritizing error prevention initiatives in Chicago; and 6. … Key Words: Action Planning; Communication; Disclosure; Error prevention; Patient Engagement; Patient … Safety; Patient Reporting of Error ***** I. … Prioritizing error prevention initiatives in Chicago; and 6.

405. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
     January 01, 2024 - With this increased complexity comes an increased risk of error and potential harm. … Error did not reach the patient. Very slight on subsequent process activity. … Page 7 3 Slight effect Error reached the patient. Patient is not harmed. … Error reached the patient. Slight effect on the patient, but patient is unharmed. … Page 8 8 Extreme effect/major injury Actual error occurred and reached the patient.

406. Common Cause Analysis: Focus on Institutional Change (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
     January 20, 2008 - and assigning blame to the error. … Error detectability can also relate to a process. … Medical care availability and reduction of error (MCARE) Act; March 20, 2002. … Error in medicine. JAMA 1994; 272: 1851-1857. 10. Nolan TW. … Michael Cohen on medication error reporting and patient safety.

407. Interplay Between Cognitive Load and Diagnostic Accuracy | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
     May 01, 2024 - errors. 25,26 In one study, radiology residents had a 12 percent increased likelihood of a diagnostic error … It may make intuitive sense that more rapid and frequently heuristic cognition is more error prone. … this example, the presence of overwhelming extrinsic load and cognitive overload leads to a diagnostic error … This error results in a missed diagnosis and lack of treatment for pneumonia, which can progress to more

408. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-pediatric-safety-refs.html
     August 01, 2023 - Diagnostic Error in Pediatrics: A Narrative Review. Pediatrics . … Diagnostic error in children presenting with acute medical illness to a community hospital. … Committee on Diagnostic Error in Health Care. Improving diagnosis in health care. … Primary care pediatricians' interest in diagnostic error reduction. Diagnosis (Berl) . … Factors Associated With Diagnostic Error on Admission to a PICU: A Pilot Study.

409. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
     August 01, 2023 - Diagnostic Error in Pediatrics: A Narrative Review. Pediatrics . … Diagnostic error in children presenting with acute medical illness to a community hospital. … Committee on Diagnostic Error in Health Care. Improving diagnosis in health care. … Primary care pediatricians' interest in diagnostic error reduction. Diagnosis (Berl) . … Factors Associated With Diagnostic Error on Admission to a PICU: A Pilot Study.

410. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
     June 01, 2023 - errors. 9 Might vary in their willingness to speak up about medical mishaps, inducing disparities in error

411. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.html
     June 01, 2023 - errors. 9 Might vary in their willingness to speak up about medical mishaps, inducing disparities in error

412. TeamSTEPPS®: Research/Evidence Base | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/evidence-base/emergency-care.html
     July 01, 2015 - Error reduction and performance improvement in the emergency department through formal teamwork training … Error reduction and performance improvement in the emergency department through formal teamwork training

413. Final Progress Report: Improved Patient Safety Through Web-Based Education (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/hendee-report.pdf
     January 01, 2024 - Healthcare Errors, Hospital Safety, Safety Education, Patient Information, Healthcare Quality, Medication Error … , Medical Error Purpose: Develop, evaluate, and disseminate web-based, population-specific education … Learning from Mistakes • Disclosure of Injuries and Errors • Retrospective Analysis • Technologies for Error … and the Culture • Breaking Down Barriers • Impact of a Close-Call Reporting System • Learning from Error … • Reporting Error and Follow Up • The Proactive Approach to Error • Health Literacy • Technology

414. Chapter 6. Assessment and Process Evaluation | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-6.html
     July 01, 2022 - Special Considerations: The National Coordinating Council for Medication Error Reporting and Prevention … This index considers factors such as whether the error reached the patient and, if the patient was harmed … Table 6 explains the different categories of medication error classification. … Different categories of medication error classification were adapted into the table below.

415. Chapter 6. Assessment and Process Evaluation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/chapter-6.html
     July 01, 2022 - Special Considerations: The National Coordinating Council for Medication Error Reporting and Prevention … This index considers factors such as whether the error reached the patient and, if the patient was harmed … Table 6 explains the different categories of medication error classification. … Different categories of medication error classification were adapted into the table below.

416. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-psychological-safety-ref.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 … Committee on Diagnostic Error in Health Care; Board of Health Care Services; Institute of Medicine; The … feedback, learning, and improvement: answering the call of the Institute of Medicine Report on Diagnostic Error

417. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-ref.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 … Committee on Diagnostic Error in Health Care; Board of Health Care Services; Institute of Medicine; The … feedback, learning, and improvement: answering the call of the Institute of Medicine Report on Diagnostic Error

418. Patient Safety Research in Medical Group Practices: Measurement and Data Challenges (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
     December 01, 2004 - found that 13.5 percent of the prescriptions written for a managed care population resulted in an error … An error may or may not result in an adverse event, which is an instance of a patient suffering the … consequences of an error. … Epidemiology of medical error. [See Comment.] BMJ 2000 Mar 18;320(7237):774–7. 4. … Medical error: what do we know? what do we do? San Francisco: Jossey-Bass; 2002. p. 325. 39.

419. Tennessee Medical Center Uses AHRQ Tools to Reduce Infections, Medical Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201710.html
     June 01, 2017 - Tennessee Medical Center Uses AHRQ Tools to Reduce Infections, Medical Errors Search All Impact Case Studies June 2017 After using principles from AHRQ's Comprehensive Unit-based Safety Program (CUSP) to reduce pressure ulcers, NorthCrest Medical Center in Springfield, Tennessee, used CUSP practices to tack…

420. Final Progress Report: Patient Safety: Physician Assistant Responsibilities and Opportunities (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/crane-report.pdf
     January 01, 2024 - When asked about their comfort level with an error prevention activity, PAs were comfortable with supporting … and advising a peer on how to respond to an error and with analyzing a case to find the cause of an … error. … PAs were less comfortable with entering a Patient Safety Net report and with disclosing an error to