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61. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - Ask: How would you describe the organization's culture relative to blame or responsibility for errors … A Just Culture supports disclosure and learning from errors and encourages viewing every event as an … Human errors are abundant and inevitably repeated when system processes are not corrected or adjusted … Only then can we learn why errors were truly made, and how we can implement policy, process, and improvement … mechanisms to prevent the same errors from happening again.

62. Final Progress Report: Leveraging a Social Network of Elders and Families To Improve Medication Safety at Transitions of Care (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/2024-01/quintana-report.pdf
    January 01, 2024 - Figure 14 demonstrates the aggregated occurrences of navigation errors in scenarios 1-3. … Adverse drug events and medication errors in Australia. … Medication errors in elderly people: contributing factors and future perspectives. … Awareness of technology-induced errors and processes for identifying and preventing such errors. … Technology-induced errors.

63. Fact Sheets | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/research/findings/factsheets/index.html
    February 01, 2024 - Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets Medical Errors … Performance Initiative Comparative Health System Performance Initiative Fact Sheet (PDF, 162 KB) Medical Errors

64. New Challenge Competition Offers Prizes for Ideas on Advancing AHRQ’s CDS Connect | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/news/newsletters/e-newsletter/881.html
    September 01, 2023 - Issue Brief Describes Strategies for Improving Clinician Psychological Safety in Reporting Diagnostic Errors … Issue Brief Describes Strategies for Improving Clinician Psychological Safety in Reporting Diagnostic Errors … describes strategies for improving clinician psychological safety in reporting and discussing diagnostic errors … The brief highlights specific barriers and challenges to reporting and learning from diagnostic errors

65. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
    May 01, 2023 - 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, … Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions … such as the use of tall man lettering in order to prevent such errors. 6. … Patient Safety Primer: Medication Errors and Adverse Drug Events 9.

66. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
    August 01, 2022 - Slide 5 Say: Multiple studies have shown that involvement in medical errors and adverse events … Medical errors. Failure-to-rescue cases. First death experiences. … Say: As referenced in Module 3, this diagram shows the distinction between adverse events and errors … , and recognizes that not all adverse events are medical errors, and not all medical errors are adverse … Therefore, it is important to recognize the distinction between medical errors and adverse events, as

67. Well-Child Visits on the Rise, But Disturbing Gaps Remain for Underserved Populations | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/news/newsletters/e-newsletter/828.html
    August 01, 2022 - AHRQ Views Blog: AHRQ Expands Its Repertoire To Eliminate Diagnostic Errors . … AHRQ Views Blog: AHRQ Expands Its Repertoire To Eliminate Diagnostic Errors In a new blog post, AHRQ … An estimated 250,000 diagnostic errors occur annually in U.S. hospitals. … Defining and studying errors in surgical care: a systematic review .

68. Ldusafety Facguide (doc file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
    May 01, 2017 - presentation, we will do the following: Describe the rationale for the use of checklists for reducing errors … Errors associated with schematic tasks are labeled “slips” and occur because of lapses in concentration … Errors associated with failures of attentional behavior are labeled “mistakes” and often occur because … Most errors in health care are slips rather than mistakes. … Checklist effectiveness for reducing errors can be enhanced when— they are created or adapted to meet

69. Additional TeamSTEPPS Videos: Check-Back in Inpatient Surgical Teams | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/teamstepps-program/resources/additional/check-back-team.html
    July 01, 2023 - instructions are described—and heard—correctly is an important safeguard against potential medication errors … part of an evidence-based approach to safer care, can improve communication and reduce the risk of errors

70. Improving Your Laboratory Testing Process Toolkit (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
    December 01, 2017 - Errors in managing tests are more common than most of us realize. … Addressing the system can reduce errors. Figure 1. … Medical testing errors in this office do not harm patients. 9. … Providers and staff openly discuss causes and effects of errors. 10. … Reduce errors in delayed notification of lab results.

71. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-111921.pdf
    March 11, 2022 - Diagnostic Safety Capacity Building Contract: o An issue brief titled The Contribution of Diagnostic Errors … Agency Update o The Evidence-based Practice Center Program draft report Diagnostic Errors

72. Meeting Minutes, April 2019 | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/news/events/nac/2019-04-nac/nacmtg0419-minutes.html
    July 01, 2019 - Brady described AHRQ’s current efforts to improve diagnosis, that is, to reduce diagnostic errors in … More than 4 million U.S. citizens each year suffer severe consequences as a result of diagnostic errors … Brady stated that the Agency’s goal is to reduce the rate of diagnostic errors occurring each year in … A reduction of 1 million diagnostic errors in 1 year would potentially result in a savings of $500 million … It has identified a pool of individuals who have experienced diagnostic errors.

73. Final report: To Quantify the Impact of the Existing vs. Enhanced Work Configuration of Radiation Therapy Technicians on Workload, Situation Awareness, and Performance during Pretreatment QA Tasks (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/2024-01/mosaly-report.pdf
    January 01, 2024 - Table 1 describes the 8 scenarios and embedded errors for each scenario. … Embedded errors were carefully constructed to be rare, but realistic. … All scenarios consisted of embedded errors (Table 1). … Relating physician’s workload with errors during radiation therapy planning. … being propagated or new errors being generated.

74. Explicit and Standardized Prescription Medicine Instructions | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/health-literacy/improve/pharmacy/instructions.html
    September 01, 2020 - Instructions Explicit, standardized instructions improve patients’ understanding, and possibly reduce errors … To improve patients' understanding, and possibly reduce errors while improving adherence, AHRQ grantee … Studies have shown that errors are more likely with more complex regimens.

75. AHRQ Research Summit on Improving Diagnosis in Health Care | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety.html
    April 01, 2019 - These errors occur in all settings of care, contribute to about 10 percent of patient deaths, and are … Substantial effort is needed to identify research priorities, including how to measure and reduce diagnostic errors

76. Hospitals and Health Systems | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/patient-safety/settings/hospital/resource/index.html
    August 01, 2022 - recommendations, and other resources for hospitals and hospital administrators to improve quality, reduce errors … Toolkits, recommendations, and other resources for long-term care facilities to improve quality, reduce errors

77. Learn about CUSP | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/hai/cusp/modules/learn/index.html
    July 01, 2018 - Discusses the effects of errors and patient harm and the underlying causes of errors.

78. Hospital Survey on Patient Safety Culture Version 2.0 (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
    January 01, 2021 - When staff make errors, this unit focuses on learning rather than blaming individuals........... 1 … 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 ............................................ … When errors happen in this unit, we discuss ways to prevent them from happening again .. 1 2 3 4

79. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care (pdf file)
    ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-110620.pdf
    March 11, 2021 - • Preventable Harm From Pediatric Outpatient Medication Errors: Measure Development: This project … The discussion included topic-specific comments around diagnostic errors related to health information

80. Patient Safety Tools | Agency for Healthcare Research and Quality
    ahrqpubs.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
    June 01, 2022 - The strategies can help prevent harmful events such as medication errors, bed sores, and healthcare-associated … Guide for Hospitals focuses on how hospitals can better identify, report, monitor, and prevent medical errors … journal and forum on patient safety and health care quality that features expert analysis of medical errors … describe accomplishments between 1999 and 2004 by federally funded programs in understanding medical errors … Web: [ in English ] Web: [ en español ] 20 Tips to Help Prevent Medical Errors tells patients