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441. AHRQ Safety Program for MRSA Prevention: Targeting SSI
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/125-cusp-science-safety.pptx
     April 01, 2025 - the numbers are startling. 1 in 10 patients are harmed during a hospital stay.1 Preventable patient error … rewarded, for providing essential safety-related information, but clear lines are drawn between human error … Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-70. PMID: 10720363. … Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-70. PMID: 10720363. Heifetz R.

442. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module1/safety-modules.pptx
     March 01, 2017 - curriculum-tools/cusptoolkit/videos/07a_just_culture/index.html 17 Understanding Risk and Human Behavior1 Human Error … Care: HAIs/CAUTI Long-Term Care Safety Modules Applying Safety Principles | ‹#› 18 Managing Error … and Risk1 Human Error At-Risk Behavior Reckless Behavior Product of our current system design and

443. 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

444. Using a Tiered Approach With CUSP Principles Facilitator Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/tiered-approach-notes.docx
     April 01, 2022 - responsibility between staff and the system along with widespread commitment to eliminating the possibility of error … Accountability and justice As mentioned in Engage the CUSP Team and ICU Staff module, defects that result in error … knowledge and wisdom are some common and effective system design strategies used to minimize the risk of error … identify a mistake or harm if they feel like they or others will be blamed, shamed, or punished for human error

445. Final Progress Report: Medications at Transitions and Clinical Handoffs (MATCH) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/noskin-report.pdf
     January 01, 2024 - occur in the prescribing phase,2 and studies have demonstrated that there is an increased risk of error … Obtaining medication histories is a challenging, high-risk, error-prone activity. … resulted in patient harm during hospitalization, and 59% may have resulted in patient harm if the error … The potential longer-term risk was also assessed if the error continued for 2 weeks post-discharge, … may have resulted in patient harm during hospitalization, and 66.7% may have resulted in harm if the error

446. Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blike.pdf
     January 01, 2003 - This area of treatment was chosen because children are a high-risk, low-error-tolerance subset of all … Patient-Apnea Task-Code dispatching failure Practitioner-Attentional error and strategic error. … Operating at the sharp end: the complexity of human error. Chapter 13, In: Bogner S, editor. … Human error in medicine. Mahweh, NJ: Lawrence Erlbaum Associates; 1994. 22. … Human error. New York: Cambridge University Press; 1990. 28. Hoffman RR, Woods DD.

447. Safety Climate on Hospital Units: A New Measure (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
     January 01, 2004 - Studies of nurses’ perceptions of medication administration error reporting, the reasons that medication … Voluntary Hospital Association (VHA) have developed safety culture measures in conjunction with the error … Error, stress, and teamwork in medicine and aviation: cross sectional surveys. … Human error in hospitals and industrial accidents: current concepts. … Perceived barriers to medical-error reporting: an exploratory investigation.

448. Final Progress Report: Clinical Decision Support Simulations for Medication Administration Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/moss-berner-report.pdf
     January 01, 2024 - The Impact of computerized physician order entry on medication error prevention. … Operating at the sharp end: The complexity of human error. In: Bogner M, editor. … Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994. 7. … Human error: models and management. British Medical Journal. 2000;320:768-70. 10. … Technological system solutions to clinical communication error.

449. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/corbett.html
     August 01, 2017 - and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Error … Full disclosure when harm occurs from a medication error is a best practice. … A system of medical error disclosure. Qual Saf Health Care 2002; 11:64-8. 28. … Patient Safety Primer: Error disclosure . … Teaching medical error disclosure to physicians-in-training: A scoping review.

450. Final Progress Report: Developing a Framework to Study and Improve Communication to Enhance Diagnostic Quality in the ED (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/mahajan-manojlovich-report.pdf
     January 01, 2025 - interventions that should be either developed or tested for effectiveness in preventing diagnostic error … A conservative estimate of diagnostic error present in 5% of visits translates to ~7 million cases of … ED-based diagnostic error per year, with nearly half having the potential for patient harm.1 2 The … National Academies of Sciences, Engineering, and Medicine (NASEM) defined diagnostic error as “the … looking ahead to how we could develop interventions to improve communication and reduce diagnostic error

451. Catheter-Care-Quiz-Key (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-care/catheter-care-quiz-key.docx
     March 01, 2017 - Determine the catheter care error. … Determine the catheter care error.

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

453. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - Institute of Medicine reported that 44,000 to 98,000 patients are killed each year due to medical error … Though the links between sleep deprivation and medical error rates have only recently been definitively … Medical error and adverse drug events are uncomfortable topics for many clinicians. … Any reported error or event was pursued by the chart reviewers, who collected additional information … The impact of computerized physician order entry on medication error prevention.

454. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/131-ss-swiss-cheese.pptx
     April 01, 2025 - Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-70.  … Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-70. PMID: 10720363.​

455. Appendix B. Technical Expert Panel Members (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/hotline/hotline-appendix_b.pdf
     June 02, 2025 - University of Massachusetts, Boston Helen Haskell Founder and President, Mothers Against Medical Error

456. Final Progress Report: Developing a Medical Biometric Identification System with a Secure Database Network That Can Access Electronic Medical Databases (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/sohn-report.pdf
     January 01, 2024 - Unfortunately, the most popular identifier, wristbands, is proving to have an unacceptable error rate … The  wristband  error  rates  were  tracked  over  a  2‐year  period.  … The  mean  wristband  error  rate  for  the  first  quarter  was  7.4%.  … However,  by  the  eighth  quarter,  the  mean  wristband  error  rate  had  fallen  to  3.05%.  … Ten  percent  of  the  hospital  participants  had  error  rates  of  10.9%  or greater. 

457. Guide Promotional Postcard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
     April 01, 2018 - Annually, 1 in 20 outpatients experiences a diagnostic error 55% of patients said diagnostic errors

458. Mod4-System-Focused-Event-Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
     April 01, 2016 - If the focus is on the process and the system factors that facilitated the error, the process can be … adjusted to minimize human error, resulting in fewer opportunities to err again. … If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … – Ask questions such as “Why was there human error? … ■ Were there features of the device that facilitated error?

459. Hospital Survey on Patient Safety (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
     June 02, 2025 - Patient Safety Instructions This survey asks for your opinions about patient safety issues, medical error … · An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … years or more SECTION I: Your Comments Please feel free to write any comments about patient safety, error

460. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
     January 01, 2024 - Key Words: failure modes and effects analysis, oral medication, antineoplastic drug, medication error … We planned to categorize reports by drug, disease, type and severity of injury, and error type. … The distribution of error types across the stages of the medication use process is shown in Table 2. … Medication errors, by stage of medication process Medication Error Ordering Dispensing Administration … 3 (30.0) 2 (40.0) 5 (50.0) 0 (0.0) Dispensing error 0 (0.0) 0 (0.0) 9 (100.0) 0 (0.0) Other* 2 (33.3