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461. Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician’s Office (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Galt.pdf
     April 23, 2004 - Error management Most offices had a formal system in place for reporting an actual error in the employment … site, and indicated they report hazardous situations that could lead to an error. … Error disclosure to patients was the general practice reported by these offices. … exchange of information that could contribute to future error prevention. … must be changed to improve office error-reduction practices.

462. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-2.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Introduction Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introduct…

463. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-2.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Introduction Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introduct…

464. Diagnostic Safety Research Priorities and Opportunities | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-pediatric-safety-4.html
     August 01, 2023 - NAM report Improving Diagnosis in Healthcare highlighted the critical deficiencies in diagnostic error … The report identified four broad priority research topics related to diagnostic error 60 : Patient … children’s conditions compared with their own. 39 Partnership with parents in preventing diagnostic error

465. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - An organization must expect error and train staff to recognize and recover. 2. … To facilitate the work involved in decreasing error frequency, Trinity Health needed first to collect … In a culture of blame, the focus is on human error rather than on root causes. … However, too many processes in health care still rely on human perfection to prevent error. … Error in medicine.

466. 2018 Hospital SOPS Database Report Executive Summary Infograpic (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsrptexecsum_0.pdf
     March 01, 2018 - change Areas of potential for improvement for most hospitals 470/o Nonpunitive Response to Error … composites 35% of hospitals Increased by 5 percentage points or more on Non positive Response to Error

467. Using the AHRQ Hospital Survey on Patient Safety Culture as an Intervention Tool for Regional Clinical Improvement Collaboratives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Adams-Pizarro_109.pdf
     January 08, 2008 - In “Human Error: Models and Management,”7 James Reason describes the attributes 1 of high-reliability … Feedback and communication about error. 3. Frequency of events reported. 4. … Nonpunitive response to error. 7. Organizational learning/continuous improvement. 8. … Provide feedback about reported errors to staff Nonpunitive response to error Implement effective … Human error: models and management. BMJ 2000; 320: 768-770. 8. Marx D.

468. Nurses’ Role in Diagnosis, Through the Lens of Distributed Cognition | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses3.html
     August 01, 2022 - Areas for Future Research Conclusion References The landmark report on diagnostic error … Any shortcomings in eliciting all relevant information from a patient can contribute to diagnostic error … perspective and language use contribute to framing effects and context errors that may lead to diagnostic error

469. Tool 3O: Postfall Assessment for Root Cause Analysis | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/root-cause.html
     January 01, 2013 - 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.

470. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14295%20Shenep-draft-1.pdf
     June 01, 2005 - With this increased complexity comes an increased risk of error and potential harm. … Error did not reach the patient. Very slight on subsequent process activity. … Page 7 3 Slight effect Error reached the patient. Patient is not harmed. … Error reached the patient. Slight effect on the patient, but patient is unharmed. … Page 8 8 Extreme effect/major injury Actual error occurred and reached the patient.

471. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-5.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Conclusion Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introductio…

472. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-5.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Conclusion Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introductio…

473. 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/wysiwyg/research/findings/final-reports/mosaly-report.pdf
     June 30, 2020 - 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.

474. Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast - Bakdash (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-sops-teamstepps-webcast-bakdash.pdf
     January 01, 2022 - and Work Pace (4 items) • Organizational learning – Continuous Improvement (3 items) • Response to Error … • Supervisor, Manager or Clinical Leader Support for Patient Safety (3 items) • Communication About Error

475. Appendixes | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/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 … $56,167.00 $17,197.00 $11,971.00 $82,005.00 $40,983.42 $55,646.00 $69,332.00 Standard Error …         Mean Attributable Cost Calculated $8.35 $1,091.34         Standard Error … Cost Calculated $57,158.00 $39,828.00 $20,647.00 $44,331.50 $11,897.00     Standard Error

476. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/refs.html
     May 01, 2016 - The Public's Views on Medical Error in Massachusetts, Commissioned by the Betsy Lehman Center for Patient … Safety and Medical Error Reduction. … Predictors of chemotherapy patients' intentions to engage in medical error prevention. … Brief report: Hospitalized patients' attitudes about and participation in error prevention.

477. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Intr…

478. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Intr…

479. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
     January 01, 2005 - and Quality), multidisciplinary teams have been assembled to identify and address the sources of error … Advances in Patient Safety: Vol. 2 390 mistake and potential consequences of the error. … Error reduction as a systems problem. In: Bogner MS, editor. Human error in medicine. … Human error: their causes and reduction. In: Bogner MS, editor. Human error in medicine. … The use of failure mode effect and criticality analysis in a medication error subcommittee.

480. Learning From Narratives About Diagnostic Experience | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-4.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Learning From Narratives About Diagnostic Experience Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnosti…