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421. 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

422. Understanding SOPS Surveys: A Primer for New Users - Gray (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops101-3-gray-2018.pdf
     January 01, 2018 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management … supports accurate diagnoses – Conduct research to assist in identifying processes and sources of error

423. Iqi Comp
     www.ahrq.gov/downloads/monahrq/sas/IQI_Comp.SAS
     June 01, 2015 - *; *-------------------------------------*; %let _EFIERR_ = 0; /* set the ERROR … put compLB @; put compUB ; ; end; if _ERROR_ then call symputx('_EFIERR_',1); /* set ERROR

424. Iqi Comp V1 1
     www.ahrq.gov/downloads/monahrq/sas/IQI_Comp_V1_1.SAS
     June 01, 2015 - . *; *-------------------------------------*; %let _EFIERR_ = 0; /* set the ERROR … put compLB @; put compUB ; ; end; if _ERROR_ then call symputx('_EFIERR_',1); /* set ERROR

425. Psi Comp
     www.ahrq.gov/downloads/monahrq/sas/PSI_Comp.SAS
     June 01, 2015 - *; *-------------------------------------*; %let _EFIERR_ = 0; /* set the ERROR … put compLB @; put compUB ; ; end; if _ERROR_ then call symputx('_EFIERR_',1); /* set ERROR

426. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-slides.pptx
     June 01, 2021 - Human Error. Cambridge: Cambridge University Press; 1990.  … Human Error. Cambridge: Cambridge University Press; 1990.  1. … Human Error. Cambridge: Cambridge University Press; 1990.  1. … Human Error. Cambridge: Cambridge University Press; 1990.  1. … Human Error.

427. Final Progress Report: Using Barcode Technology to Improve Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14053-Gandhi-draft-1.pdf
     April 16, 2007 - Initial work focused on determining the baseline dispensing error rate, type, and severity before implementation … The physicians assessed the level of harm that could have been caused by each error, had it not been … To this regard, we developed a medication administration error observation instrument. … assessors to the purpose of study; and excluded the controlled substance fill process (a process with low error … rates at baseline) from the study, which may bias the combined decrease in error rates toward a larger

428. Using the AHRQ Medical Office Survey on Patient Safety Culture Webinar - Hickner (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/hickner-development-medical-office-sops.pdf
     January 01, 2011 - Feedback & communication about error 3. Frequency of event reporting 4. … Nonpunitive response to error 7. Organizational learning--continuous improvement 8. … Communication about error 12.

429. Final report: To Quantify the Impact of the Existing vs. Enhanced Work Configuration of Radiation Therapy Technicians on Workload, Situation Awareness, and Performance during Pretreatment QA Tasks (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/mosaly-report.pdf
     January 01, 2024 - Table 1: Description of simulated scenarios and corresponding embedded error in each scenario Scenario … Description Embedded Error 1. … The error detection and procedural compliance was calculated as the average score of error detection … and/or missing information, 1 denotes proper documentation of error and/or missing information). … An alpha of 0.05 was used for an acceptable type-I error for statistical significance.

430. Creating Standards for Communication and Resolution When Things Go Wrong | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-gallagher.html
     May 01, 2020 - medical training when he couldn’t find guidelines for physicians on how to talk with patients when an error

431. Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/health-literacy/professional-training/lepguide/chapter2.html
     September 01, 2020 - They do not receive training on what constitutes an error or a near miss, or on how to report these when … It focuses on removing stigma associated with medical errors to allow an open environment of error reporting … Use medical error reporting as a learning tool for greater hospital staff understanding, and expand the … to better understand root causes and high-risk scenarios, and develop strategies for improvement and error

432. Standardizing Ambulatory Care Procedures in a Public Hospital System to Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdf
     January 01, 2004 - This error-reduction strategy will also improve communication between the patient and their physicians … Most studies that report on medical error are primarily focused on hospitalized patients. … In many individual hospital data systems, data may be extracted regarding medical error by examining … We used the characteristics of an error focus strategy as outlined by Layde et al.,6 to implement the … Error in medicine. JAMA 1994;272:1851– 7. Advances in Patient Safety: Vol. 4 162 6.

433. Fallpxtool3O (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3o.docx
     January 01, 2008 - Short Portable Mental Status Questionnaire Question Response Error? … * A mistake on ANY part of this question should be scored as an error. … -7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment * One more error … One less error is allowed if the patient has had education beyond the high school level.

434. Issue Brief 7. Improving Education: A Key to Better Diagnostic Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/dxsafety-issuebrief-education.pdf
     March 11, 2022 - Diagnostic error in internal medicine. … Cognitive interventions to reduce diagnostic error: a narrative review. … Overconfidence as a cause of diagnostic error in medicine. … Clinical reasoning and diagnostic error: a call to merge two worlds. … Nurses, diagnosis, and diagnostic error.

435. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-1.html
     June 01, 2020 - that organizations use to detect patient safety concerns cannot always specifically detect diagnostic error

436. TeamSTEPPS® Diagnosis Improvement: Module 7: Putting It All Together (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module7-presenters-notes.pdf
     January 01, 2008 -                                                                             • Summarize diagnostic error … Slide 3 Diagnostic Error Is a Patient Safety Issue Getting  the  right  diagnosis  in  a  timely … Diagnostic error is a patient safety issue. … Every member of the team can help prevent a diagnostic error. … It is an effective antidote to many of the problems that lead to diagnostic error: overconfidence,

437. TeamSTEPPS® Diagnosis Improvement: Module 7: Putting It All Together (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module7-presenters-notes.pdf
     January 01, 2008 -                                                                             • Summarize diagnostic error … Slide 3 Diagnostic Error Is a Patient Safety Issue Getting  the  right  diagnosis  in  a  timely … Diagnostic error is a patient safety issue. … Every member of the team can help prevent a diagnostic error. … It is an effective antidote to many of the problems that lead to diagnostic error: overconfidence,

438. Module 2: Communication and Optimal Resolution (CANDOR) Toolkit Module 2: Obtaining Organizational Buy-in and Support
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module2/module2-obtaining-organizational-buy-in-support.pptx
     August 14, 2015 - Reckless behavior—Choosing to consciously disregard a substantial and unjustifiable risk. 9 Managing Error … and Risk5,6 Module 2 10 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

439. Appendixes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-appendix.html
     November 01, 2017 - adverse drug reaction"[tiab] OR "adverse drug reactions"[tiab] OR "medication errors"[mh] OR "medication error … Mean Attributable Cost Calculated $6,721.00 $786.00 $5,483.00         Standard Error … Y Year of Cost Data 2007 Mean Attributable Cost Calculated $3,936.00 Standard Error … Year of Cost Data       Mean Attributable Cost Calculated       Standard Error … 1991 l 2009 Mean Attributable Cost Calculated $2,247 $3,802 $13,806 Standard Error

440. Final Progress Report: Improving Transplant Med Safety through a Pharmacist-Led, mHealth-Based Program (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/taber-report.pdf
     January 01, 2024 - demonstrated that approximately two thirds of transplant recipients will experience at least one medication error … Of more concern, nearly one in eight kidney transplant recipients will experience a medication error … The type of medication error was recorded and included both administrative and clinical subtypes. … Medication error severity was determined using a previously validated scale. … All 68 participants in both arms experienced at least one medication error during the study.