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21. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/diagnostic-safety/tools/index.html
    March 01, 2024 - primary care offices consistently show that the process for managing tests is a significant source of error … a checklist and other resources to help patients understand what they can to do prevent diagnostic error … Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error

22. Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/health-literacy/professional-training/lepguide/chapter2.html
    September 01, 2020 - They do not receive training on what constitutes an error or a near miss, or on how to report these when … It focuses on removing stigma associated with medical errors to allow an open environment of error reporting … Use medical error reporting as a learning tool for greater hospital staff understanding, and expand the … to better understand root causes and high-risk scenarios, and develop strategies for improvement and error

23. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
    July 05, 2023 - Thus, capitation and payer integration lie to the left of direct error penalties in . … What is Diagnostic Error?: Improvediagnosis.org. diagnostic-error/ [Accessed 26 Jul 2022]. 6. … Payment innovations to improve diagnostic accuracy and reduce diagnostic error. … Interventions targeted at reducing diagnostic error: systematic review. … Diagnostic error inmedicine: analysis of 583 physician-reported errors.

24. Medical Errors and Patient Safety | Agency for Healthcare Research and Quality
    www.talkingquality.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 …

25. TeamSTEPPS Diagnosis Improvement Course | Agency for Healthcare Research and Quality
    www.talkingquality.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.

26. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.talkingquality.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

27. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    www.talkingquality.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

28. Just Culture Webcast November 2016 (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-transcript-508-compliant.pdf
    June 01, 2017 - to feature Celeste Mayer, who will talk about her experiences improving the Nonpunitive Response to Error … for this webinar, Nonpunitive Response to Error. … So, what is Nonpunitive Response to Error? What does it really consist of? … to what we call Response to Error, to include more Just Culture principles in the survey items. … There is a section for Nonpunitive Response to Error.

29. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
    www.talkingquality.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.

30. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
    www.talkingquality.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

31. FileNewTemplate
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module5.pptx
    January 01, 1995 - Cross-Monitoring is… A process of ongoing monitoring to recognize risk or unfolding error An opportunity … prevention and/or error interruption mechanism for the team, ensuring that mistakes or oversights are … The insurer realized their error and covered the mammogram. … The insurer realized their error and covered the mammogram. … A shared mental model serves as an error reduction strategy, and caregivers who understand the plan monitor

32. PRIMARY CARE OFFICE-BASED TEAMS Situation Monitoring
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module5/5_ts_office_sitmon-ig.pptx
    January 20, 2006 - Cross-monitoring is a process of ongoing monitoring of the environment of care to recognize risk or unfolding error … Cross-monitoring is not a way to “spy” on other team members, but a way to provide a safety net or error … prevention/error interruption mechanism for the team, ensuring that mistakes or oversights are caught … The insurer realized their error and covered the mammogram.  … A shared mental model serves as an error reduction strategy, and caregivers who understand the plan monitor

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

34. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.talkingquality.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

35. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.talkingquality.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?

36. TeamSTEPPS for Office-Based Care: Situation Monitoring | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/teamstepps/officebasedcare/module5/office_sitmon-ig.html
    September 01, 2015 - Cross-monitoring is a process of ongoing monitoring of the environment of care to recognize risk or unfolding error … Cross-monitoring is not a way to "spy" on other team members, but a way to provide a safety net or error … prevention/error interruption mechanism for the team, ensuring that mistakes or oversights are caught … The insurer realized their error and covered the mammogram.  … A shared mental model serves as an error reduction strategy, and caregivers who understand the plan monitor

37. Agency for Healthcare Research and Quality | Agency for Healthcare Research and Quality
    www.talkingquality.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

38. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
    www.talkingquality.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

39. Appendix A: Recommendations for Staff Training | Agency for Healthcare Research and Quality
    www.talkingquality.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

40. Executive Summary | Agency for Healthcare Research and Quality
    www.talkingquality.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