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481. Learning From Narratives About Diagnostic Experience | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/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…

482. Making Healthcare Safer Practices: 12. Infusion Pumps (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/infusion-pumps-1.pdf
     March 01, 2020 - Many newer infusion pumps are equipped with predetermined clinical guidelines, dose error reduction … Infusion device standardisation and dose error reduction software. … Nearly 48% (47.9%) of infusions had at least one procedural or documentation error. … Error rates were similar. … Infusion rate errors were the leading type of serious medication error.

483. Chapter 2. Electronic Searchable Catalog | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program2.html
     April 01, 2018 - Clinical area— the medical specialty related to the article, including in which field the case/error … Error types— classification of error(s) in order to identify root cause(s) and offer solution(s). … Data Entry The data entry process was designed to minimize error in abstraction through a series of … To reduce the possibility of error and facilitate use of the query tool, there are only two write-in … , and Root Cause Analysis will also be selected because they are specific examples of Error Analysis.

484. Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
     April 01, 2021 - system for hospitalized patients, and Project 2 addressed the common but understudied area of diagnostic error … Bridging the gap between systems-based and cognitive contributions to diagnostic error . … Bridging the gap between systems-based and cognitive contributions to diagnostic error .

485. AHRQ's Patient Safety Culture Survey Targets Improvement at Cincinnati Children's Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0605.html
     October 01, 2014 - The lowest areas were for "non-punitive response to error" and "hospital handoffs and transitions." … "The low score for non-punitive response to error was surprising to us," Dresselhaus admits, "because

486. AHRQ Patient Safety Research Spurs Development of 100 Emergency Department Pharmacies | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips1305.html
     July 01, 2013 - The Institute of Medicine has identified medication errors as the most common type of error in health … practitioners who are directly impacting improvements in care and patient safety in the highly intense, error-prone

487. Understanding SOPS Surveys: A Primer for New users -Gray (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/2-SOPS_101_Webcast_2020-Gray.pdf
     January 01, 2020 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management … • Diagnostic Safety (Medical Office)—Spring 2021 ► Assist in identifying processes and sources of error

488. Improving Patient Safety Systems for Limited English Proficiency Patients
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pptx
     January 01, 2011 - of bilingual hospital staff as ad hoc interpreters for LEP patients, despite greater likelihood of error … populations to better understand root causes and high-risk scenarios Develop strategies for improvement and error

489. Improving Patient Safety Systems for Limited English Proficiency Patients: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pdf
     January 01, 2011 - of bilingual hospital staff as ad hoc interpreters for LEP patients, despite greater likelihood of error … to better understand root causes and high-risk scenarios  Develop strategies for improvement and error

490. Advances in Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances/index.html
     July 01, 2022 - Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff Organizational Climate, Stress, and Error … Grems, Elizabeth Sloan The Impact of a Patient Safety Program on Medical Error Reporting (   PDF , … Dittus The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence … Weinger Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? … Hilborne Standardizing Medication Error Event Reporting in the U.S.

491. Facilitator’s Implementation Roadmap: TeamSTEPPS® Diagnosis Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/dxsafety-facilitator-roadmap.pdf
     February 01, 2022 - Use the Course Infographic to provide current information pertaining to diagnostic error and its impact … Sharing data on the frequency of diagnostic error in both ambulatory and acute care settings and their

492. Facilitator’s Implementation Roadmap: TeamSTEPPS® Diagnosis Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-facilitator-roadmap.pdf
     February 01, 2022 - Use the Course Infographic to provide current information pertaining to diagnostic error and its impact … Sharing data on the frequency of diagnostic error in both ambulatory and acute care settings and their

493. Improving Patient Safety Systems for Limited-English-Proficient (LEP) Patients: A Guide for Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
     December 01, 2012 - of bilingual hospital staff as ad hoc interpreters for LEP patients, despite greater likelihood of error … Develop strategies for improvement and error prevention.

494. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/25702-Lipsitz-draft-1.pdf
     August 31, 2022 - Two physicians independently reviewed each TCE to determine if a medical error had occurred. … combined in a third model to identify factors that conferred a higher risk for experiencing a medical error … geriatrician and hospitalist who reached consensus about whether a particular event was a medical error … In 14.7% of all discussions, a medical error was identified. … Furthermore, it suggests that the discharging service and time of day may be associated with risk of error

495. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/25702-Lipsitz-report.pdf
     August 31, 2022 - Two physicians independently reviewed each TCE to determine if a medical error had occurred. … combined in a third model to identify factors that conferred a higher risk for experiencing a medical error … geriatrician and hospitalist who reached consensus about whether a particular event was a medical error … In 14.7% of all discussions, a medical error was identified. … Furthermore, it suggests that the discharging service and time of day may be associated with risk of error

496. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
     January 01, 2019 - Feedback and Communication About Error .............................................................. … Feedback and Communication About Error 1. … Missed nursing care is a subset of the category known as error of omission. … Nonpunitive Response to Error 1. … Feedback and Communication About Error Composite 6. Communication Openness Composite 7.

497. Environmental Scan of Patient Safety Education and Training Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
     June 01, 2013 -  Error types—classification of error(s) in order to identify root cause(s) and offer solution(s) … Data Entry The data entry process was designed to minimize error in abstraction through a series of … To reduce the possibility of error and facilitate use of the query tool, there are only two write-in … , and Root Cause Analysis will also be selected because they are specific examples of Error Analysis … Reducing Medical Error Reducing Patient Injuries Safer Patients Teach Patient Safety Root

498. Advances in Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/advances/index.html
     October 01, 2014 - Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff Organizational Climate, Stress, and Error … Grems, Elizabeth Sloan The Impact of a Patient Safety Program on Medical Error Reporting (   PDF File … Hargarten Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative … Weinger Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? … Hilborne Standardizing Medication Error Event Reporting in the U.S.

499. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/health-literacy/professional-training/lepguide/app-f.html
     September 01, 2020 - to better understand root causes and high-risk scenarios, and develop strategies for improvement and error

500. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
     May 05, 2008 - On error management: Lessons from aviation. Br Med J 2000; 320: 781-785. 4. Reason J. … Human error. Cambridge, UK: Cambridge University Press; 1990. 6. Hagland M. … Operating at the sharp end: The complexity of human error. In: Bogner M, ed. … Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum; 1994. 33. Reason J. … Safety in the operating theatre – Part 2: Human error and organisational failure.