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21. Medical Errors and Patient Safety | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/research/findings/factsheets/errors-safety/index.html
    January 01, 2023 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

22. TeamSTEPPS Diagnosis Improvement Course | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/teamstepps-program/diagnosis-improvement/index.html
    February 01, 2024 - Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error … Helen Haskell, M.A., Mothers Against Medical Error.

23. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
    October 01, 2023 - Walsh received a 3-year AHRQ grant in 2015 to identify the factors that contribute to medication error

24. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-fac-guide.html
    July 01, 2023 - Can you identify examples of human error in your unit or hospital? … Slide 16: Managing Error and Risk 3 Say: To improve outcomes, human error, at-risk behavior, and … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console providers who have committed a human error and to ensure

25. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
    January 01, 2004 - A “medical error” is defined as the failure of a planned action to be completed as intended (error … Numerous studies have documented the impact of human error on patient safety. … Human error. New York: Cambridge University Press; 1990. 7. Reason J. … Human error: models and management. BMJ 2000;7237:768–70. 8. Ternov S. … Error reduction as a systems problem. In: Bogner, MS, editor. Human error in medicine, pp.67– 91.

26. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
    March 01, 2024 - Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating … 23 percent of patients treated at 29 academic medical centers in the U.S. experienced a diagnostic error … by Agency-funded research teams that have published essential insights into areas such as diagnostic error

27. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
    August 01, 2022 - occurring in 5 percent of ED visits translates to about 7 million cases of ED-based diagnostic error … What interventions could reduce diagnostic error in emergency departments? … inform diagnosis and error. … Interdisciplinary communication: an uncharted source of medical error? … Diagnostic error in medicine: analysis of 583 physician-reported errors.

28. Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdf
    May 01, 2017 - • Can you identify examples of human error in your unit or hospital? … SAY: To improve outcomes, human error, at-risk behavior, and reckless behavior each should be managed … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console providers who have committed a human error and to ensure

29. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.html
    August 01, 2022 - Slide 9 Say: To improve outcomes, human error, at-risk behavior, and reckless behavior should … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console providers who have committed a human error and to ensure … Forcing functions, checks, and redundancies are some features of systems intended to minimize the risk of error

30. Advances in Patient Safety | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/reports/advances/index.html
    July 01, 2022 - Grems, Elizabeth Sloan The Impact of a Patient Safety Program on Medical Error Reporting (   PDF , 177 … 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. … Hoonakker Development and Validation of the Medication Administration Error Reporting Survey (   PDF

31. Appendix F: PowerPoint Presentation: Executive Summary | Agency for Healthcare Research and Quality
    www.cahps.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

32. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/funding/grantee-profiles/grtprofile-bell.html
    March 01, 2022 - “AHRQ is helping to pioneer a novel 360-degree approach to diagnostic error prevention by bringing patients … process so there’s a corrective mechanism that’s possible before it leads to duplication, diagnostic error … Among patients who reported a diagnostic error, the most common contributing factor patients reported … AHRQ’s vision to take such a pioneering stance on tackling the complex issue of ambulatory diagnostic error

33. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - 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. … (Table 1) Table 1: Behavior Classification Normal Error (Human Error) At-risk Behavior Reckless … If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … questions such as "Why was there human error?

34. Agency for Healthcare Research and Quality | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/cpi/about/mission/ahrq-fy2015-conf-spending.html
    January 01, 2016 - Total Non-Feds on Travel:  0 Center for Quality Improvement and Patient Safety (CQUIPS) Diagnostic Error … and final of three annual conferences to be held as part of the large conference grant "Diagnostic Error … response to the AHRQ funding mechanism PAR09-257 and supports the AHRQ/CQUIPS program to reduce medical error

35. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/topics/fed-IWG-dxsafety-Nov19mtg.pdf
    November 15, 2019 - • Grants To Enable Diagnostic Excellence (4 awarded) CDC • Literature review linking laboratory error … grants.nih.gov/grants/guide/rfa-files/RFA-HS-19-001.html https://www.ahrq.gov/patient-safety/diagnostic-error-grants

36. Appendix A: Recommendations for Staff Training | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/app-a.html
    September 01, 2020 - educational sessions in this area: Include a focus on the definition of a patient safety event or medical error … Survey on Patient Safety Culture , evaluate whether training has made staff more likely to report an error

37. Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/settings/ambulatory/diagnostic-safety/toolkit.html
    November 01, 2018 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

38. Executive Summary | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/exec-summary.html
    September 01, 2020 - the doctor's conversation in Spanish with the patient been interpreted for the rest of the team, this error … to better understand root causes and high-risk scenarios, and develop strategies for improvement and error … Family members may also suffer psychological harm if they make an error in interpretation that results

39. Chapter 1: Background on Patient Safety and LEP Populations | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/chapter1.html
    September 01, 2020 - Identifying something as an adverse event does not imply "error," "negligence," or poor quality care. … Never event ** : The term "never event" refers to a particularly shocking medical error (such as wrong-site … Most exams that are automatically scheduled are chest exams and so I performed one in error.

40. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
    March 01, 2017 - Can you identify examples of human error in your unit or facility? … Slide 19: Managing Error and Risk 1 Say: To improve outcomes, human error, at-risk behavior, and … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console team members who have committed a human error and to ensure