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81. AHRQ's Quality & Patient Safety Programs by Setting: Ambulatory Care | Agency for Healthcare Research and Quality
    cahps.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

82. Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families | Agency for Healthcare Research and Quality
    cahps.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 .

83. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
    cahps.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

84. TeamSTEPPS Module 1: Introduction (Instructor Guide) (pdf file)
    cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module1/igintro-cx062819.pdf
    January 01, 2007 - will be able to: • Describe the TeamSTEPPS Master Trainer course; • Describe the impact of errors … • How can we prevent medical errors? … 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. … Finally, your team will be safer, allowing the team to more readily identify and correct errors, if

85. AHRQ News Now | Agency for Healthcare Research and Quality
    cahps.ahrq.gov/news/newsletters/e-newsletter/index.html
    April 30, 2024 - 2024 Health Literacy–Informed Intervention Reduces Pediatric Caregiver Liquid Medication Dosing Errors … Researchers Identify Risk Factors for Pneumonia After Cardiac Surgery January 9, 2024 Diagnostic Errors … Prevention Primary May 9, 2023 Issues With Electronic Health Records Contribute to Diagnostic Errors

86. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    cahps.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.

87. Final Progress Report: Leveraging a Social Network of Elders and Families To Improve Medication Safety at Transitions of Care (pdf file)
    cahps.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.

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

89. New Challenge Competition Offers Prizes for Ideas on Advancing AHRQ’s CDS Connect | Agency for Healthcare Research and Quality
    cahps.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

90. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
    cahps.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.

91. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    cahps.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

92. TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) (pdf file)
    cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/teamattitude.pdf
    March 21, 2014 - Teams that do not communicate effectively significantly increase their risk of committing errors. … Poor communication is the most common cause of reported errors. 27.

93. Well-Child Visits on the Rise, But Disturbing Gaps Remain for Underserved Populations | Agency for Healthcare Research and Quality
    cahps.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 .

94. Ldusafety Facguide (doc file)
    cahps.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

95. Additional TeamSTEPPS Videos: Check-Back in Inpatient Surgical Teams | Agency for Healthcare Research and Quality
    cahps.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

96. Improving Your Laboratory Testing Process Toolkit (pdf file)
    cahps.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.

97. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
    cahps.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

98. Meeting Minutes, April 2019 | Agency for Healthcare Research and Quality
    cahps.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.

99. AHRQ-Funded Patient Safety Research Featured in Health Affairs | Agency for Healthcare Research and Quality
    cahps.ahrq.gov/patient-safety/reports/healthaffairs.html
    March 01, 2019 - commitment to lead patient-safety efforts nationwide, AHRQ has funded studies that aim to reduce medication errors … improve communication strategies that support better care coordination, and lower the rate of diagnostic errors

100. About the Toolkit Development | Agency for Healthcare Research and Quality
     cahps.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
     July 01, 2023 - addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication errors … High-reliability systems and a culture of learning from errors (or near misses) are needed to minimize