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461. Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.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

462. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=19
     January 01, 2024 - September 2005 Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error … Health Information Exchange, Rural Settings Publication Date: September 2005 Quality Care and Error

463. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=17
     January 01, 2024 - Human Factors Approaches To Improve Patient Safety Publication Date: December 2006 Medication Error … Measure Development Publication Date: September 2006 Validation of an Innovative Approach To Error

464. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=20
     January 01, 2024 - 20 21 22 next › ›› last » Last » Minimizing Error … Care, Human and Environmental Factors Publication Date: September 2004 Conference on Medical Error

465. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=13
     January 01, 2024 - Improve Patient Safety, Risk Assessment Publication Date: November 2009 Conference: Diagnostic Error … Publication Date: September 2009 Pediatric Medication Safety: Analyses from the MEDMARX Medication Error

466. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-110620.pdf
     March 11, 2021 - and Safety of Diagnosis and o Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … • Diagnostic Error in Medicine (DEM) Conference: A presentation based on the AHRQ measurement issue

467. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
     April 20, 2004 - of paper MARs in tandem with electronic BCMA documentation) increase the probability of medication error … of PRN medications for CABG patients were documented in the BCMA system, so the risk of medication error … Patient Safety: Vol. 3 448 Cultural and management issues Elimination of a punitive medication error … Following root-cause analysis of the barriers to the BCMA software implementation, the medication error … errors was an option only when the error was associated with a criminal or purposefully unsafe act

468. Action Planning for the SOPS Surveys Webcast Transcript (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/action-planning-webcast-transcript.pdf
     June 01, 2019 - We are below the database on Feedback and Communication About Error, Nonpunitive Response to Error and … , Staffing, Nonpunitive Response to Error, and Handoffs and Transitions. … We've also increased our Nonpunitive Response to Error from 30% positive to 41% positive. … While we're below the database and similar sized hospitals on Nonpunitive Response to Error, we have … Feedback and Communication About Error is the extent to which staff are informed about errors.

469. 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

470. | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/publications/search.html?page=3
     September 01, 2022 - Safety Issue Brief #6: This issue brief discusses what is known about the contribution of diagnostic error … Safety Issue Brief #5: Despite the enormous financial cost and patient harm resulting from diagnostic error

471. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=15
     January 01, 2024 - Engagement, Safe Practices Publication Date: November 2008 Using Team Simulation to Improve Error … Development and Implementation Publication Date: June 2008 Problem Density, Workload, and Medical Error

472. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
     August 01, 2022 - Addressing the problem of diagnostic error by understanding and optimizing the diagnostic process in

473. Action-Alliance-Agenda-040323 Locked (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-agenda-040323_LOCKED.pdf
     April 25, 2023 - President, Consumers Advancing Patient Safety Founder and President Mothers Against Medical Error

474. Final Progress Report: Auditory Perception of Drug Names: Neighborhood Effects (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/lambert3-report.pdf
     January 01, 2024 - Drug companies and regulators screen names prior to approval, but the screening process is itself error … The root mean squared error of prediction was 17.52%, and the mean absolute error was 14.65%. … Physicians produced two types of error in the perception task. … An evaluation of the quality of the USP/ISMP Medication Error Reporting Program. … Institute of medicine medical error figures are not exaggerated.

475. Diagnostic Safety Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
     May 01, 2023 - is to create a well-organized office system that fosters sound medical decision making, minimizes error … www.improvediagnosis.org/practice-improvement-tools/open-notes/ Open Notes addresses multiple aspects of diagnostic error … AudioandVideo/WIHIImprovingDiagnosisErrors.aspx In this podcast from IHI, four speakers discussed diagnostic error … kp_shortcut_referrer=kp.org/scal/dex The videos in this series are short and cover a wide range of diagnostic error … and educators on clinical reasoning, critical thinking, and system factors that underlie diagnostic error

476. Medical Injury Identification Using Hospital Discharge Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
     January 01, 2003 - While the IOM report primarily emphasized error reporting systems, focusing on the injuries or adverse … Most current patient safety reporting systems focus on incidence of medical error or negligence. … Perceived blame and punishment for error, however, may be an incentive for concealment and denial. … those resulting from malpractice damages.2 In addition, the determination of negligence or medical error … believe this injury prevention approach is a useful complement to other approaches that focus on error

477. Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Dickerman_84.pdf
     June 04, 2008 - cold” by the Institute of Medicine’s (IOM) 1999 report, To Err Is Human.2 1 The Nature of Error … established the theoretical basis for this understanding through their work in the study of human error … The unit cost per life saved is enormous. 2 How the Environment Contributes to Error What … Error in medicine. JAMA 1994; 272: 1851- 1857. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. … Human error. Cambridge, UK: Cambridge University Press; 1990. 4. Perrow C.

478. Clinical Pharmacists in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-fairbanks_20.pdf
     February 21, 2008 - Emergency medicine: A practice prone to error? CJEM 2001; 3: 271-276. 4. … Promoting patient safety and preventing medical error in emergency departments. … Human error. New York: Cambridge University Press; 1991. 28. Sanders MS, McCormick EJ. … Justifying a pediatric critical-care satellite pharmacy by medication-error reporting. … Defining, identifying, and measuring error in emergency medicine.

479. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
     June 18, 2008 - patients receiving PCA therapy and implementation of “smart” (computerized) PCA pumps containing dose-error … Our multidisciplinary Medication Error Team includes pharmacists, respiratory therapists, risk managers … team determined that implementation of a modular, computerized IV infusion safety system with dose error … PCA Practice and Patient Monitoring Recognizing opioids’ potential for harm, the Medication Error Team … Conclusion Data indicate that the use of “smart” PCA infusion devices with dose error-reduction systems

480. Chapter 1. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2014/mosurv14chap1.html
     June 01, 2014 - research pertaining to safety, patient safety, health care quality, ambulatory medicine, medical errors, error … It was designed to assess medical office staff opinions about patient safety issues, medical error, and