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401. 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.

402. “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.

403. 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.

404. 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

405. 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

406. 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.

407. 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.

408. 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.

409. Cuestionario sobre la de seguridad de los pacientes en los hospitales (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital_survey-spanish.pdf
     June 02, 2025 - • Un “incidente” es definido como cualquier tipo de error, equivocación, evento, accidente o desviación … Cuando se comete un error, pero es descubierto y corregido antes de afectar al paciente, ¿qué tan a … Cuando se comete un error, pero no tiene el potencial de dañar al paciente, ¿qué tan frecuentemente … Cuando se comete un error que pudiese dañar al paciente, pero no lo hace, ¿qué tan a menudo es reportado

410. Surveys on Patient Safety Culture (SOPS) Hospital 2.0 Survey: 2022 User Database Report Part II (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2022-hsops2-database-report-appendixes.pdf
     January 01, 2022 - Response to Error 68% 67% 64% 62% 61% 60% 59% 60% 9. … Communication About Error 71% 74% 75% 73% 72% 6. … Response to Error 61% 65% 64% 63% 62% 9. … Communication About Error 79% 72% 70% 74% 6. … Communication About Error 71% 80% 6.

411. Surveys on Patient Safety Culture (SOPS) Hospital 2.0 Survey: 2021 User Database Report Part II (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2021-HSOPS2-Database-Report-Part-II-508.pdf
     January 01, 2021 - Response to Error 66% 68% 63% 65% 60% 62% 60% 9. … Communication About Error 69% 72% 74% 71% 7. … Communication About Error 68% 75% 73% 73% 66% 66% 7. … Response to Error 64% 66% 65% 65% 62% 60% 9. … Communication About Error 77% 69% 69% 72% 7.

412. Meeting Minutes, November 2015 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/nac/2015-11-nac/nacmtg1115-minutes.html
     May 01, 2016 - It evaluated diagnostic error as a quality-of-care challenge and examined the epidemiology, burden of … harm, economic costs of error, and efforts to address the problem. … He described diagnostic error issues, such as the fact that diagnostic error is notoriously difficult … Dedicated funding for diagnostic error projects at AHRQ has been modest during the past dozen years. … We need longitudinal data on diagnostic error, and we need to determine error rates.

413. Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
     April 06, 2008 - the Act outline its main features.1, 2, 3, 4 The Act reflects the need for voluntary reporting of error … has been slow.7, 8, 9, 10 Moreover, it is recognized that the detection, by itself, of an event or error … As such, the health care organization must participate in error reporting for its own benefit and to … Medical error reporting system still a year off. … Human error. Cambridge, UK: Cambridge University Press; 1990. 14. Institute of Medicine.

414. 124-Cusp-Science-Safety-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
     April 01, 2025 - In the United States (U.S.), preventable patient error in hospitals is among the leading causes of death … Teams strive to learn from the event and to take steps to prevent the same error from recurring. … This reduces the risk that future patients will be harmed by the same type of error. … In many cases, the error would have happened again, regardless of the individual provider. … James Reason, an early influential researcher on human error and patient safety, wrote, “Rather than

415. AHRQ Grant Final Progress Report: Real-Time, Wireless, Networked Feedback for Bed-Tilt Compliance (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/thomas1-report.pdf
     January 01, 2024 - The human error perspective requires the analysis of individual moments at which the desired behavior … Subjective assessment of backrest elevation: Magnitude of error. … Error in medicine. JAMA-J Am Med Assoc 1994;272(23):1851-1857. 42. Reason J. … Safety in the operating theatre, part 2: Human error and organisational failure. … Error, stress, and teamwork in medicine and aviation: Cross-sectional surveys.

416. A Process-centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Akins.pdf
     January 01, 2003 - A system of medical error disclosure. Qual Saf Health Care 2002;11;64–8. 26. Smetzer JL. … Medication error prevention: profiling one of pharmacy’s foremost advocacy efforts for advice on error … Human error. New York: Cambridge University Press; 1990. 41. Hatch D. … Developing a proactive approach to medication error prevention. … Nine steps to move forward from error. Cognition, Technology & Work 2002: 4;137–44. 45.

417. Appendix B10: Primary Care Provider Fax Report and Orders (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb10pcptxt.html
     December 01, 2017 - If you have received this fax in error, please notify the sender immediately and shred/destroy all documents … If you have received this fax in error, please notify the sender immediately and shred/destroy all documents

418. Just Culture Webcast Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-2-presentation.pdf
     May 01, 2007 - 2007 – Chief of Staff – 2007 - 2014 – General Counsel – 2014 - present Non-punitive Response to Error … University of North Carolina Health System UNC Medical Center My Role Non-punitive Response to Error

419. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/fed-IWG-dxsafety-Nov19mtg.pdf
     November 15, 2019 - • Grants To Enable Diagnostic Excellence (4 awarded) CDC • Literature review linking laboratory error … grants.nih.gov/grants/guide/rfa-files/RFA-HS-19-001.html https://www.ahrq.gov/patient-safety/diagnostic-error-grants

420. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/assess-psc-hsop-slides.pptx
     January 01, 2017 - - 4 CULTURE OF SAFETY Teamwork processes (backup behavior) Resource allocation practices Error-detection … learning–continuous improvement Teamwork within unit Communication openness Feedback and communication about error … Nonpunitive response to error Staffing Hospital management support for patient safety Teamwork across … Feedback and communication about error We are given feedback about changes put into place based on event … HSOPS Sample Questions 10 COMPOSITE SCORES (DIMENSIONS) SAMPLE QUESTION Nonpunitive response to error