Results

Total Results: 1,289 records

Showing results for "error".
Users also searched for: medication errors

1. Error Disclosure Training and Organizational Culture | Agency for Healthcare Research and Quality
   www.qualitymeasures.ahrq.gov/patient-safety/reports/liability/etchegaray.html
   August 01, 2017 - vs. 41 percent), serious error disclosure (79 percent vs. 58 percent), trust-based error disclosure … , minor error (i.e., error that causes harm that is neither permanent nor life-threatening) disclosure … disclose this error. … The improvements in minor error disclosure culture and serious error disclosure culture observed between … Minor Error Disclosure Serious Error Disclosure Error Disclosure Trust Safety Culture Teamwork

2. Table 6: Categories of Medication Error Classification | Agency for Healthcare Research and Quality
   www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/match/table-6.html
   August 01, 2012 - Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Table 6: Categories of Medication Error … , capacity to cause error NA B Error that did not reach the patient NA C Error that reached … cause harm (omissions considered to reach patient) Multivitamin was not ordered on admission D Error … Anticoagulant, such as warfarin, was ordered daily when the patient takes it every other day G Error … necessitated intervention to sustain life Anticonvulsant therapy was inadvertently omitted I Error

3. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
   www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
   April 27, 2022 - Three studies operationalized error using existing definitions only. … in published peer-reviewed diagnostic error research?” … error work is to improve the care of patients.” … Clinician survey on diagnostic error Clinician survey on diagnostic error Accuracy Timeliness … Patients’ perspectives of diagnostic error: a qualitative study.

4. Grants to Enable Diagnostic Excellence | Agency for Healthcare Research and Quality
   www.qualitymeasures.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
   January 01, 2021 - machine learning models that can be used to retrospectively identify patients in whom a diagnostic error … https://www.ahrq.gov/patient-safety/diagnostic-error-grants/index.html  

5. Hand Hygiene Observational Audit Tracking Tool (xls file)
   www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
   December 01, 2021 - :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR

6. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)
   www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
   January 01, 2016 - Diagnostic Error Measures: For Quality Improvement & Patient Safety Research Diagnostic Error Measures … Diagnostic Error Measures Types of Patient Safety & Quality Measures xxVoluntary Reporting Chart … trigger report • PPV > 70% • Requires programming • Fully automated IOM Definition: Diagnostic Error … JAMA. 2001;285:2114-2120 Wrong-Patient Error Measures Retract-and-Reorder Tool Applied to Complete … Diagnostic Error Measures:�For Quality Improvement & �Patient Safety Research Slide Number 2 Slide

7. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
   www.qualitymeasures.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
   January 01, 2024 - As the lead Federal agency investing in research to improve diagnostic safety and reduce diagnostic error … MB) Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Emergency Departments  ( PDF , 3 MB) Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Defining diagnostic error: a scoping review to assess the impact of the national academies' report improving

8. Medications Supplement Dashboard Data 2023 (xls file)
   www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/Medications_Supplement_Dashboard_Data_2023.xlsx
   January 01, 2023 - Report Type Frequency Percent Incorrect action (process failure or error) (e.g., such as administering … overdose or incorrect medication) Incident 97,070 70.5% Incorrect action (process failure or error) … ) Harm 341 6.1% Incorrect patient/family action (e.g., self-administration error) No Harm 5,282 93.9% … error) Storing 116 1.9% Incorrect patient/family action (e.g., self-administration error) Transcribing … error) Storing 492 5.0% Incorrect patient/family action (e.g., self-administration error) Transcribing

9. The Timeline to Diagnostic Safety SIDM -Research as a Priority (pdf file)
   www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
   January 01, 2017 - Which is more error prone – intuition or normative approach? … What’s the Cost of Dx Error? Understanding the costs of dx error would motivate ….. … ” • Add these slides if Victor doesn’t cover them Diagnostic Error Error-related Harm 40,000 … – 80,000 deaths/yr The Toll of Dx Error Leape et al. … What’s the Cost �of Dx Error?

10. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-insertion/unlicensed-staff/scenario-instr.docx
    March 01, 2017 - · Some scenarios may have only one error while others will have more. · Consider using TeamSTEPPS for … Error/Corrective Action: Hand hygiene was not performed upon entering or leaving the room. … Error/Corrective Action: Gloves should be worn when handling a resident’s catheter, the catheter tubing … Error/Corrective Action: Both staff members should be wearing gloves since both are handling either the … Error/Corrective Action: Hand hygiene should always be performed when exiting a resident’s room.

11. Brain Based Learning Strategies to Improve TeamSTEPPS® Deployment and Health Care High Reliability | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/teamstepps/events/webinars/jan-2017.html
    January 01, 2017 - Error Management Theory Slide 41. Error Management Learning Paradigm Slide 42. … Error Management Theory Slide 43. Error Management Theory Slide 44. … Error Management Theory Slide 45. Error Management Theory Slide 46. … detection , and how best to manage the error, or error recovery . … Return to Contents   Slide 46 Error Management Theory A study about Error Management Theory

12. Breakout 1 (morning): Use of Data and Measurement in Reducing Error (video) | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-agenda/breakout1-video.html
    August 01, 2017 - Summit on Diagnostic Safety Breakout 1 (morning): Use of Data and Measurement in Reducing Error … Conferences Breakout 1 (morning): Use of Data and Measurement in Reducing Error … 2017 Internet Citation: Breakout 1 (morning): Use of Data and Measurement in Reducing Error

13. Breakout 2 (afternoon): Use of Data and Measurement in Reducing Error (video) | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-agenda/breakout2-video.html
    August 01, 2017 - on Diagnostic Safety Breakout 2 (afternoon): Use of Data and Measurement in Reducing Error … Conferences Breakout 2 (afternoon): Use of Data and Measurement in Reducing Error … 2017 Internet Citation: Breakout 2 (afternoon): Use of Data and Measurement in Reducing Error

14. Just Culture Webcast Closing (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-3-closing.pdf
    June 01, 2017 - Just Culture Webcast Closing Updating the Hospital Survey and Nonpunitive Response to Error • HSOPS … and a pilot study – Version 2.0 to be released in early 2018 – Revising the Nonpunitive Response to Error … composite to reflect Just Culture concepts 31 Nonpunitive Response to Error Response to Error … quality-patient-safety/patientsafetyculture/index.html Updating the Hospital Survey and NonpunitiveResponse to Error

15. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2023.xlsx
    January 01, 2023 - The tables include the relative frequencies by type of device, by device defect, failure or use error … Total Unknown 57.1% 19,960 34,962 Device defect or failure, including HIT 30.1% 10,531 34,962 Use error … 8.9% 3,124 34,962 Combination or interaction of device defect or failure and use error 3.9% 1,347 34,962 … defect or failure, including HIT 90.9% 2664 9.1% 266 8,236 Unknown 93.4% 3329 6.6% 235 8,236 Use error … 83.6% 1016 16.4% 199 8,236 Combination or interaction of device defect or failure and use error 82.5%

16. Action Planning for the SOPS Surveys-Results (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-yount-sops-action-planning-tool.pdf
    June 01, 2019 - Events Reported 65 Communication Openness 64 Teamwork Across Units 62 Feedback & Communication About Error … 62 Staffing 50 Nonpunitive Response to Error 41 Handoffs & Transitions 37 33 34 Comparing to the … 62 69 69 Staffing 50 53 55 Nonpunitive Response to Error 41 47 50 Handoffs & Transitions 37 48 49 … 62 69 69 66 Staffing 50 53 55 56 Nonpunitive Response to Error 41 47 50 30 Handoffs & Transitions 37 … 62 69 69 66 Staffing 50 53 55 56 Nonpunitive Response to Error 41 47 50 30 Handoffs & Transitions 37

17. Breakout Session: Use of Data and Measurement in Improving Diagnostic Safety (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/brady-summit2016-breakout.pdf
    September 28, 2016 - www.ahrq.gov/news/newsroom/press- releases/2015/saving-lives.html What Makes Addressing Diagnostic Error … • Who owns the Dx error problem? … NAM (formerly IOM) Definition of Diagnostic Error The failure to: (a) establish an accurate and timely … Measuring Diagnostic Error • Research projects • Medical liability claims • Patient safety and quality … NAM (formerly IOM) �Definition of Diagnostic Error Recommendations from �the Improving Diagnosis in

18. Just Culture Webcast Intro (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-1-intro.pdf
    November 09, 2016 - Feedback & communication about error – 3. Frequency of event reporting – 4. … Nonpunitive response to error – 7. Organizational learning--continuous improvement – 8. … Nonpunitive Response to Error Survey Items – Staff feel like their mistakes are held against them. … Lowest Performing Composite Results –2016 AHRQ Comparative Database Defining Nonpunitive Response to Error … Nonpunitive Response to Error Survey Items

19. Device or Medical/Surgical Supply, Including HIT Dashboard | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/npsd/data/dashboard/devices.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

20. Silence A Commentary | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - This is what it feels like when you lose a loved one to a medical error. … , a systems error, or both. … In some cases, it may be a provider or team that takes responsibility for the error; in other cases, … In the past, patients experienced only silence and abandonment after a medical error. … The many faces of error disclosure: A common set of elements and a definition .