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101. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
     May 20, 2016 - with drug reaction ∗ Death associated with adverse drug reaction ∗ Death associated with medication error … Procedures  Prophylaxis  Resuscitation  Supervision/management  Triage/transitions  Human error … usual procedures performed in accordance with standards of care) and nosocomial infections  Human error … Multi-professional mortality review: supporting a culture of teamwork in the absence of error finding

102. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
     July 14, 2023 - Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare March Meeting Summary Workgroup Goal: Established in response to Senate Report 115-150. The Senate Committee on Appropriations requested “AHRQ t…

103. Hospital Survey on Patient Safety Culture Version 2.0 Spanish (pdf file)
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2-0-Spanish-5-26-2021.pdf
     January 01, 2021 - • Un “evento de seguridad del paciente” se define como cualquier tipo de error, equivocación, o incidente … Cuando se descubre un error y se corrige antes de que afecte al paciente, ¿con qué frecuencia se reporta … Cuando un error afecta al paciente y pudo haberle causado daño, pero no fue así, ¿con qué frecuencia

104. Resources | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/questions/resources/index.html
     November 01, 2020 - 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 …

105. Peer Review: Study Section Descriptions | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/funding/process/study-section/peerdesc.html
     July 01, 2017 - 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 …

106. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-slides.html
     March 01, 2017 - Slide 18: Understanding Risk and Human Behavior 1 Human Error: Inadvertently completing the wrong … Slide 19: Managing Error and Risk 1 Human Error At-Risk Behavior Reckless Behavior

107. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
     July 01, 2004 - explicit review is a patient-centered process focusing on patient harm rather than provider or system error … As opposed to a provider-centered focus of error elimination, fault tolerance attempts to create systems … , our design assumes that the leverage point for improvement interventions is fault tolerance, not error … To that end, we have no measures of individual provider performance or provider error. … of our nation’s health care delivery systems reaches beyond the limitations of identifying provider error

108. Improving Your Laboratory Testing Process Toolkit (pdf file)
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
     December 01, 2017 - primary care offices consistently show that the process for managing tests is a significant source of error … Some of the tools can help you identify error-prone aspects of your lab testing process, and others … Any of these steps can be a source of error if the office system allows it. … each step. • Circle the number that you feel most accurately describes the harm associated with the error … Design a change to reduce error in your office system by using a Planning for Improvements tool.

109. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
     January 01, 2024 - 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 …

110. New Toolkit Can Improve Post-Surgery Complications and Enhance Patient Recovery | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/news/newsletters/e-newsletter/870.html
     June 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 …

111. Identifying Strategies to Improve Medication Safety at Home | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/funding/grantee-profiles/grtprofile-xiao.html
     November 01, 2022 - 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 …

112. Spanish Medical Office Survey on Patient Safety Culture Items and Dimensions (pdf file)
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/resources/modim_sp.pdf
     December 01, 2011 - Spanish Medical Office Survey on Patient Safety Culture Items and Dimensions D-1 Spanish Translation of AHRQ’s Medical Office Survey on Patient Safety December 2011 This document explains the process that was used to develop a Spanish translation of the Agency for Healthcare Research and Quality (AHRQ) Medica…

113. FileNewTemplate
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module9.pptx
     March 07, 2019 - FileNewTemplate Module 9: Change Management Office-Based Care Online Course Welcome to the Welcome to the TeamSTEPPS for Office-Based Care Online Course. This is Dr. Brigetta Craft. This presentation will cover Module 9, Change Management, that you, as a practice facilitator, will review. 1 The Materials You …

114. VHA's Journey to High Reliability: Advancing Toward Zero Harm and Becoming a Learning Health System
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/action-alliance/high-reliability-journey-slides.pptx
     September 26, 2023 - any event that causes disruption to safe and reliable operations across the system Unclear Policy Error … network of peer-to-peer connections Foundational training in HRO concepts, Just Culture principles and error

115. NPSD Dashboards | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/npsd/data/dashboard/index.html
     October 01, 2023 - the type of device; type of device by residual harm to the patient; device defect, failure, or user error … ; device defect, failure, or user error by residual harm to the patient; type of health information technology

116. Final Progress Report: Leveraging a Social Network of Elders and Families To Improve Medication Safety at Transitions of Care (pdf file)
     www.cpsi.ahrq.gov/sites/default/files/2024-01/quintana-report.pdf
     January 01, 2024 - The high ICC indicates that the independent coders introduced a minimal amount of measurement error, … Technology induced error and usability: the relationship between usability problems and prescription

117. Biosketches | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-biosketches.html
     September 01, 2016 - She was a member of the IOM Committee on Diagnostic Error in Healthcare. … In 2008 he originated the Diagnostic Error in Medicine conference series, in 2011 he founded the Society … journal, DIAGNOSIS, devoted to improving the quality and safety of diagnosis and reducing diagnostic error … Haskell is president of the nonprofit patient organizations Mothers Against Medical Error and Consumers … Since the medical error death of her young son Lewis in 2000, Ms.

118. Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/patient-safety/reports/liability/waever.html
     August 01, 2017 - and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Error … A culture of patient safety reflects the values, assumptions, and norms related to communication, error … and report data on relationships between patient safety culture, liability related processes (e.g., error … Error disclosure: a new domain for safety culture assessment. BMJ Qual Saf 2012; 21:594–9. 15. … Medical error: the second victim. The doctor who makes the mistake needs help too.

119. Advancing Diagnostic Equity Through Clinician Engagement, Community Partnerships, and Connected Care (pdf file)
     www.cpsi.ahrq.gov/sites/default/files/wysiwyg/topics/advancing-diagnostic-equity.pdf
     November 15, 2022 - About 1 in 20 US adults experience a diagnostic error in the outpatient setting annually,3 but this … marginalized patients, who face additional biases, discrimination, and structural fac- tors.4 Diagnostic error

120. Implementation Change Management | Agency for Healthcare Research and Quality
     www.cpsi.ahrq.gov/teamstepps-program/curriculum/implement/activity/change.html
     June 01, 2023 - Avoiding this error and other errors is key to achieving the culture of safety TeamSTEPPS promotes.