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141. Findings | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3.html
     July 01, 2018 - . 25 , 27 When errors do occur, patients tend to think individual providers cause them, not the systems … However, providers—like consumers and patients—may also view errors as individual deficiencies that are … Patients define patient safety more narrowly in terms of medical errors. … In addition, providers may feel that errors are primarily under an individual's control and therefore … Available at http://www.ahrq.gov/patients-consumers/care-planning/errors/5steps/index.html Return

142. Christiana Care Health System: Safety Mentor Program (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell_94.pdf
     March 30, 2008 - the Institute of Medicine, as many as 98,000 patients die each year because of preventable medical errors … The Christiana Care Health System is committed to eliminating preventable medical errors. … is going to have greater difficulty identifying system issues that contribute to errors. … that positive process changes have occurred because these errors are being identified. … “Concerning patient safety and medical errors.” Testimony before U.S.

143. Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/index.html
     January 01, 2007 - To Improve Diagnostic Safety and Quality Find AHRQ tools to reduce diagnostic errors … on Diagnostic Safety and Quality Learn about AHRQ's research to better understand how diagnostic errors … Diagnostic errors occur in all settings of care, contribute to about 10 percent of patient deaths, and … AHRQ funds research to better understand how diagnostic errors happen and what can be done to prevent … Tools To Improve Diagnostic Safety AHRQ has several tools to reduce diagnostic errors

144. Did You Know, Safety Infographic (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
     August 01, 2021 - attend a primary care appointment this year will experience a diagnostic error.2 79% of diagnostic errors … are related to the patient-clinician encounter.3 up to 56% of these errors are related to miscommunication … Types and origins of diagnostic errors in primary care settings.

145. Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/diagnostic-safety-transitions-care.pdf
     June 01, 2023 - In addition to cognitive errors of omission and commission, communication errors may follow similar … Second, and relatedly, early diagnostic errors can propagate other types of medical errors such as admission … Diagnostic errors in medicine: a case of neglect. … The importance of cognitive errors in diagnosis and strategies to minimize them. … Cognitive errors detected in anaesthesiology: a literature review and pilot study.

146. Using Specialized Information Technology to Reduce Errors in Emergency Cardiac Care (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Daudelin.pdf
     January 01, 2000 - Using Specialized Information Technology to Reduce Errors in Emergency Cardiac Care 7 Using Specialized … errors. … IT to Reduce Cardiac Care Errors 9 Figure 1. … IT to Reduce Cardiac Care Errors 11 Figure 3. … IT to Reduce Cardiac Care Errors 17 2.

147. Imbedding Research in Practice to Improve Medication Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Raebel_53.pdf
     May 07, 2008 - Results: All interventions reduced errors (range, 13 to 45 percent), with more than 4,000 errors avoided … Detection of potential errors triggered alerts. … Examining systems issues that contribute to near-misses or errors. … Medication errors were reduced in all projects. … Medication errors drop with Kaiser alert system. Rocky Mountain News; May 27, 2005. 4.

148. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - Discussion: The models provide contextual maps of the errors and behaviors that lead to medication … However, pharmacy dispensing errors—internal or external—that enter the facility are captured in the … per medication order, and errors per oral medication dose. … errors in a district general hospital. … Errors today and errors tomorrow. N Engl J Med 2003;348:2570–2. 24. Blegen MA, Vaughn T.

149. Discussion of Findings | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/findings.html
     March 01, 2017 - within this domain may include errors in referral and errors in communicating test results. … . 39 , 70 , 97–101 Errors occur at the prescribing, filling, and administration stages of medication … Prescribing errors included prescribing the wrong medication, prescribing medications with drug-drug … interactions, and making errors related to transcription of written prescription orders. … Efforts to reduce medication errors in the ambulatory care setting, including primary care, have focused

150. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Schiff (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new_sops_diagnostic_safety-schiff.pdf
     January 01, 2020 - • Frequent • Important • Overlooked • Matter • Not easy to measure 17 Frequent - #1 Type of Errors … Diagnostic errors 2. Opioid safety across the continuum of care 3. … • Spotty follow-up • Most diagnoses resolve,…or evolve w/errors unnoticed • Elusive to capture with … Research and Quality's activities in patient safety research IOM Report September 2015 Diagnosis Errors … Frequent -#1 Type of Errors Most Common Types of Medical Error Experienced by MA Residents 21% Experienced

151. AHRQ Workshop Bolsters New Jersey Patient Safety Act | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/ockt0504.html
     October 01, 2014 - advocacy groups learned from Federal and State officials about efforts being made to prevent medical errors … and professionals accountable for their conduct and encouraging honest disclosure and analysis of the errors … New Jersey law, enacted April 27, 2004, creates a non-punitive system for the reporting of medical errors … The goal of the law is to create a health care culture that focuses on preventing errors by improving … Until now, fear of litigation has made health care professionals reluctant to discuss errors.

152. Brain Based Learning
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps_webinar_012017.pptx
     January 01, 2017 - Rather than avoid errors, learners are asked to embrace errors as part of the initial events of learning … Medical Teacher, 2011, 33:1, 34-38 Obvious Errors (Others) Subtle Errors (Others) Obvious Errors (Self … when errors are not detected, Learners get more information on how to detect them. … all errors need to be represented—slips, errors, mistakes Dror I. … to perform subtle errors and the other team grade them (they circle the errors they will perform ahead

153. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
     January 01, 2018 - to Improve Safety Tejal Gandhi Handwriting 16 Ways IT Can Improve Safety • Prevent errors … and providing feedback about adverse events Bates, Gawande 2003 Main Strategies for Preventing Errors … decision support Bates, Gawande 2003 Optimize the Use of HIT • We know that some technologies reduce errors … • Overdependence on technology • Shift in power • Never-ending technology demands • Emotions • New errors … Use of HIT to Improve Safety Handwriting Ways IT Can Improve Safety Main Strategies for Preventing Errors

154. Guide Promotional Postcard (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
     April 01, 2018 - Annually, 1 in 20 outpatients experiences a diagnostic error 55% of patients said diagnostic errors … 9 ED admissions are related to an adverse drug event An estimated 160 million medication errors … Reduce errors and improve efficiency by setting the visit agenda together with Be Prepared To Be

155. Producing Accurate Clinical Quality Reports for Population Health: A Delivery System-Oriented Approach to Report Validation (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/ehr-reports.pdf
     March 01, 2016 - They found no errors in the report logic. … For validation purposes it is useful to categorize clinical quality report errors into “inclusion errors … Other inclusion errors can be caused by workflow issues, which are errors caused by failure to note … Exclusion Errors The fact that with exclusion errors the patient is not in the report means that the … All reports contain errors, and 2.

156. Designing Consumer Reporting Systems for Patient Safety Events: Project Overview (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
     July 01, 2011 - since the Institute of Medicine raised national awareness of the prevalence and severity of medical errors … between 44,000 and 98,000 deaths in U.S. hospitals each year are the result of preventable medical errors … Consumer reporting systems may greatly improve our understanding of the nature and causes of medical errors … improved understanding of patient safety and assist in the detection of patterns associated with medical errors

157. Speaking Plainly: Communicating the Patient’s Role in Health Care Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Miranda.pdf
     July 01, 2004 - Others specified particular actions that patients could take to avoid errors, such as maintaining a … refers to “medical errors.” … Agency for Healthcare Research and Quality: 20 tips to help prevent medical errors. … Preventing medical errors: communicating a role for Medicare beneficiaries. … Prescription errors tied to lack of advice: pharmacists skirting law, Mass. study finds.

158. The Impact of a Patient Safety Program on Medical Error Reporting (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Woolever.pdf
     January 01, 2001 - Medical facilities have long had systems in place to monitor errors. … Formal teamwork training improved teamwork and reduced emergency department errors. … A look into the nature and causes of human errors in the intensive care unit. … Medical Team Management: using teamwork to prevent medical errors. … Treat systems, not errors, experts say. JAMA 1996;276:1537–8. 23.

159. The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Karsh.pdf
     April 08, 2004 - , the impact of errors on patient and care systems, and methods to control errors. … , how to design systems with proper defenses against errors, and communication skills. … • Understanding that some latent errors and systemic problems are exacerbated by poor design. … The authors also note that even though people argue that systems problems contribute to medical errors … than systems errors.

160. Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance (pdf file)
     ce.effectivehealthcare.ahrq.gov/downloads/pub/advances/vol1/Schillinger.pdf
     January 01, 2004 - Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance … 199 Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen … medication adherence in the treatment of chronic diseases7 and can help prevent medication-related errors … Reducing medication-related communication errors will likely involve rigorous reviews of medication … Factors related to errors in medication prescribing. JAMA 1997 277(4):312–7. 9.