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41. Identifying Strategies to Improve Medication Safety at Home | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/funding/grantee-profiles/grtprofile-xiao.html
    November 01, 2022 - Medication errors that occur at home, especially during transitions of care such as patient discharge … The preventable harms for these medication errors include adverse drug events (ADEs), unscheduled hospital … There is an increased potential for medication errors as more responsibilities of medication management … Xiao identified frequent errors that occurred during the placement of central lines or central venous

42. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
    January 01, 2022 - , MPH*† Objectives: A lack of consensus around definitions and reporting standards for diagnostic errors … A lack of consensus around definitions and reporting standards for diagnostic errors limits the extent … Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.

43. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
    July 14, 2023 - • EPC Program o Released the final report Diagnostic Errors in the Emergency Department: A Systematic … CDC • Division of Laboratory Systems o Health Equity and Diagnostic Errors: DLS envisioned and is … /grants/guide/rfa-files/RFA-HS-23-011.html https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency … /research https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency/research https:// … • Preventable Harm From Pediatric Outpatient Medication Errors: Measure Development o Project

44. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
    January 01, 2024 - Potential problems include medication errors, falls, infections, procedural complications, management … errors, diagnostic errors, lack of adequate monitoring, and lack of timely follow-up care. … human factors experts, and systems engineers—who developed an approach for investigating diagnostic errors

45. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
    January 01, 2019 - By the end of the workshop, participants should: • Be introduced to an understanding of why errors … It makes the case that true transparency will result in improved outcomes, fewer medical errors, more … It highlights bright spots: organizations that use a just culture approach to investigating errors, … Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans To Enhance Safety … The best practices are designed to help alert hospitals and focus their efforts on errors that cause

46. Hospital Survey on Patient Safety Culture Version 2.0: Composites and Items (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
    August 01, 2019 - When staff make errors, this unit focuses on learning rather than blaming individuals. A13. … In this unit, there is a lack of support for staff involved in patient safety errors. … We are informed about errors that happen in this unit. C2. … When errors happen in this unit, we discuss ways to prevent them from happening again. C3.

47. TeamSTEPPS Fundamentals Course: Module 1. Introduction | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/teamstepps/instructor/fundamentals/module1/igintro.html
    June 01, 2019 - Describe the impact of errors and why they occur. Describe the TeamSTEPPS framework. … How can we prevent medical errors? … Return to Contents Barriers to Team Performance Say: Errors can occur for many reasons, and … Many obstacles also can impair an individual or team's ability to work effectively and prevent errors … It was determined that 43 percent of errors resulted from problems with team coordination.

48. Meeting Minutes, November 2015 | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/news/events/nac/2015-11-nac/nacmtg1115-minutes.html
    May 01, 2016 - 2015, Summary Report Director's Update Health Information Technology Real World Use of MEPS Diagnostic Errors … Return to Contents Diagnostic Errors Elizabeth A. … the results of a large study, conducted by the Institute of Medicine (IOM), on reducing diagnostic errors … AHRQ and others should encourage and facilitate the voluntary reporting of diagnostic errors and near … is focusing on three goals from the IOM report—goal 6 concerning improving learning from diagnostic errors

49. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
    August 01, 2022 - Thus, it is no wonder that diagnostic errors occur. … Diagnostic Errors in the Emergency Department: A Sys- tematic Review. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Changes in medi- cal errors after implementation of a handoff program. … The importance of cognitive errors in diagnosis and strategies to minimize them.

50. TeamSTEPPS 2.0 Module 8: Change Management
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule8.pptx
    March 28, 2006 - After completing this module, you'll be able to list the eight steps of change, identify errors common … Practices Step 3: Prioritize Best Practices Step 4: Review Kotter’s 8 Steps of Change Step 5: Common Errors … And then step five, common errors. … Discuss what some of the common errors are when trying to make an organizational change. … listed on the following slide. 18 Errors Common to Organizational Change (Slide 12) Common errors:

51. Quality and Patient Safety Resources | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/resources/index.html
    December 01, 2022 - Quality and Patient Safety Resources Tips for preventing medical errors … Patient Safety Measure Tools & Resources Information about AHRQ efforts to reduce medical errors and

52. Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/research/publications/search.html
    January 01, 2024 - Diagnostic Safety Issue Brief #15 One of the best ways to collect information about diagnostic errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors

53. Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/research/publications/search.html?page=0
    January 01, 2024 - Diagnostic Safety Issue Brief #15 One of the best ways to collect information about diagnostic errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors

54. Tool: Check-Back (or Repeat-Back) | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
    July 01, 2023 - Some misunderstandings lead to serious medical errors, including misdiagnoses. … The message may also be misunderstood because of typing errors or autocorrected spellings that change … What communication errors were avoided?

55. Resource List - AHRQ Hospital Survey (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
    April 01, 2023 - Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans To Enhance Safety … It makes the case that true transparency will result in improved outcomes, fewer medical errors, more … This article lists 10 tools to assist in better patient handoff communications and to avoid errors. … The best practices are designed to help alert hospitals and focus their efforts on errors that cause … Patient Safety Primer: Medication Errors and Adverse Drug Events 23.

56. TeamSTEPPS, Module 8: Change Management (Instructor Guide) (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module8/igchangemgmt.pdf
    February 25, 2014 - CHANGE MANAGEMENT: HOW TO ACHIEVE A CULTURE OF SAFETY SUBSECTIONS • Eight Steps of Change • Errors … Errors Common to Organizational Change 17 2 mins 5. … COMMON ERRORS TO CHANGE (5 Minutes) 1. … Compare the errors to those found presented on the slide that accompanies page 17. … Kotter identifies ways to institutionalize change and counter these errors.

57. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
    August 01, 2022 - Slide 7 Say: It is important to understand the distinction between events and errors when an … Errors are defined as an act of commission (doing something wrong) or omission (failing to do the right … The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … and errors that are not adverse events.

58. AHRQ's Quality & Patient Safety Programs by Setting: Ambulatory Care | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/ambulatory/index.html
    July 01, 2022 - Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit  aims to assist primary care practice teams … with a systematic approach to reduce diagnostic errors among children in three important areas: Elevated … Ambulatory Settings is designed to help staff actively engage patients and their care partners to prevent errors

59. Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/reports/engage/medlist.html
    October 01, 2022 - strategy helps to improve documentation because we can see the medications and decrease medication errors … In the primary care setting, medication safety issues include prescribing errors, contraindications, … That’s at least 160 million medication errors annually .

60. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
    September 01, 2022 - Cross-Cutting: Health Information Technology Cross-Cutting: Other Topics Delirium Diagnostic Errors … Infection Control: Urinary Tract Infection Patient and Family Engagement Patient Identification Errors … Patients Summary of Evidence (Not reviewed) (Not reviewed) Fatigue, Sleepiness, and Medical Errors …   MHS I (2001) MHS II (2013) MHS III (2020) Patient Safety Practices Targeted at Diagnostic Errors … Radiological Patient Safety Practices  MHS I (2001) MHS II (2013) MHS III (2020) Reducing Errors