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Showing results for "error".
Users also searched for: medication errors

441. Briefing and Debriefing Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/briefing-debriefing.html
     December 01, 2017 - Specimens labeled correctly Clean/dirty instrument separation Equipment issues/review Operator error … versus posting error: ________________________________________________________________________

442. Tool: Briefing and Debriefing Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/briefing_debriefing.docx
     December 01, 2017 - Specimens labeled correctly · Clean/dirty instrument separation · Equipment issues/review Operator error … versus posting error: ________________________________________________________________ _____________

443. AHRQ Webcast Introducing the New SOPS Hospital Survey 2.0 - Sorra (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/3-sorra-sops-hospital-survey-2-0-webcast.pdf
     July 20, 2020 - Shifting to a “Just Culture” framework to assess Response to Error; 4. … Communication about error 2. Communication openness 3. Handoffs and information exchange 4. … Response to error 8. Staffing and work pace 9. … Difference HSOPS 2.0- HSOPS 1.0 Reporting Patient Safety Events Communication Openness Response to Error … - HSOPS 1.0 Hospita l Management Support for Patient Safety 70 Teamwork Communication About Error

444. Survey on Patient Safety (facility version) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
     June 02, 2025 - Patient Safety Instructions This survey asks for your opinions about patient safety issues, medical error … question does not apply to you, you may leave your answer blank. · An “event” is defined as any type of error … years or more SECTION I: Your Comments Please feel free to write any comments about patient safety, error

445. Survey on Patient Safety (facility version) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     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 … or more SECTION I: Your Comments Please feel free to write any comments about patient safety, error

446. Shadowing (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/shadowing.doc
     June 02, 2025 - Did you observe any error in transcription of orders by the provider you shadowed? 4. … Did you observe any error in the interpretation or delivery of an order? 5.

447. Connecting the Dots: Improving Unit Safety Culture to Stop HAI (October 8, 2013) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/connecting-dots-transcript.html
     December 01, 2017 - The NICK MERCK taxonomy for categorizing errors gives us a common language for talking about error. … 11 - James Reason is an industrial organizational psychologist that's taught us a huge amount about error … With just culture then, we just have the non-punitive response to error dimension. … So, those would be two concerns as well as non-punitive response to error. … In the dimension, non-punitive response to error.

448. Paul Tedrick (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-transcript.doc
     October 08, 2013 - The NICK MERCK taxonomy for categorizing errors gives us a common language for talking about error. … 11 - James Reason is an industrial organizational psychologist that's taught us a huge amount about error … With just culture then, we just have the non-punitive response to error dimension. … So, those would be two concerns as well as non-punitive response to error. … In the dimension, non-punitive response to error.

449. Appendix, MATCH Resources for Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/appendix/app-12.html
     July 01, 2022 - Medication Practices (ISMP) is the Nation's only nonprofit organization devoted entirely to medication error … resources including tips for using medications wisely and suggestions on what to do if you think an error

450. Appendix, MATCH Resources for Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-12.html
     July 01, 2022 - Medication Practices (ISMP) is the Nation's only nonprofit organization devoted entirely to medication error … resources including tips for using medications wisely and suggestions on what to do if you think an error

451. Final Progress Report: Training Doctors To Disclose Unanticipated Outcomes to Patients: Randomized Trial (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/gallagher3-report.pdf
     January 01, 2024 - Key Words: error disclosure, patient safety, patient-provider communication, ethics, medical malpractice … with patients about unanticipated outcomes is difficult, especially when the outcome was due to an error … To explore whether characteristics of the event (severity of harm, presence of error), the physician … Talking with patients and families about medical error: A guide for education and practice. 2010. … Accountability for medical error: Moving beyond blame to advocacy. CHEST 2011;140:519-526. 9.

452. Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-woods_79.pdf
     May 30, 2008 - Document correct patient and blood type Incorrect or illegible handwritten label Human error … If info is wrong, the Fenwal armband on patient will catch the error. … These additional steps in the medication ordering process can result in increased risk of error. … minor misplacement of a decimal point in calculating the medication dose can result in a 10-fold error … Medication error prevention “toolbox.” Medication safety alert. June 2, 1999.

453. Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Seger.pdf
     January 01, 2003 - and medication list, and applies a set of logical rules to determine a possible ADE or medication error … (ME), medication error that leads to an adverse drug event (ADE/ME), or no event. … A medication error was defined as any error that occurred in the medication use process (including ordering … The medication has a low adverse reaction profile, but the therapy is redundant and thus an error. … Increase in US medication-error deaths between 1983 and 1993. The Lancet 1998;351:643–44. 2.

454. 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.

455. 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

456. 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

457. 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

458. 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

459. NPSD Dashboards | Agency for Healthcare Research and Quality
     www.ahrq.gov/npsd/data/dashboard/index.html
     September 01, 2024 - the type of device; type of device by residual harm to the patient; device defect, failure, or user error … ; device defect, failure, or user error by residual harm to the patient; type of health information technology

460. 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.