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461. 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.

462. 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.

463. 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

464. 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.

465. 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

466. 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.​

467. 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.

468. 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.

469. 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.

470. Advances in Patient Safety and Medical Liability | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/index.html
     August 01, 2017 - and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Error … Pronovost Error Disclosure Training and Organizational Culture Jason M. Etchegaray, Thomas H.

471. 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. 

472. 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

473. 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?

474. 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

475. 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

476. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=19
     January 01, 2024 - Health Information Exchange, Rural Settings Publication Date: September 2005 Quality Care and Error … 012019 Topic(s): Diagnostic Safety, Medication Safety Publication Date: March 2005 Minimizing Error

477. 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

478. 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.

479. 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

480. 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