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201. Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
     February 21, 2008 - Medical Errors and Adverse Events at Hospital Discharge Errors and Adverse Events Are Common on Both … • Filing system errors. • Errors in dispensing medications. … • Errors in responding to abnormal laboratory test results. … Waiting days or weeks leads to errors. 6. … Medication errors observed in 36 health care facilities.

202. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
     June 15, 2003 - Data collection Both the MEDMARXSM and NNIS systems track errors and infections through individual … For MEDMARXSM, the methods used to identify potential medication errors vary across hospitals. … • Providing protection and rewards for individuals who report errors. … In: Enhancing patient safety and reducing errors in health care. … Medication errors: experience of the United States Pharmacopeia (USP) MEDMARXSM reporting system.

203. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety.html
     September 01, 2023 - Clinician Psychological Safety in Reporting and Discussing Diagnostic Error Learning From Diagnostic Errors … Improve Diagnostic Safety Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors

204. Teaching Implementation Change Management | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps-program/curriculum/team/implement/teach-change.html
     February 01, 2024 - Identify errors common to organizational change. … Common Errors Display Slide 75, “Errors Common to Organizational Change.” … This slide lists common errors to avoid. … Kotter identifies ways to institutionalize change and counter these errors. … Errors Common to Organizational Change (5 Minutes) Ask participants what some of the common errors

205. Peer Review at AHRQ - Study Sections | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/funding/process/study-section/peerrev.html
     March 01, 2024 - It reviews applications relating to identifying risks and hazards that lead to medical errors and identifying … The research findings and products encompass providing information on the scope and impact of medical errors … healthcare associated infections; and examining effective ways to make system-level changes to help prevent errors … Dissemination and translation of research findings and methods to reduce medical errors, examining effective … ways to make system-level changes to help prevent errors, and developing, testing and evaluating various

206. Understand the Science of Safety | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.html
     July 01, 2018 - How Can These Errors Happen? Slide 6. The Science of Safety Slide 7. … Return to Contents   Slide 5: How Can These Errors Happen? … Say: Errors occur within the health care setting because people are fallible. … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science.

207. Human Factors in Surgery: Shifting the Paradigm on Patient Safety | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-catchpole.html
     December 01, 2022 - Surgical errors contribute to more than 4,000 annual “never events”—shocking medical errors, such as … The project, Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery  , focuses … project, Human Factors and Systems Integration in High Technology Surgery , explores the root causes of errors … “We’re changing the clinical thinking about what errors really mean, about what systems really mean,

208. TeamSTEPPS 2.0: Module 8. Change Management | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/fundamentals/module8/igchangemgmt.html
     March 01, 2019 - Errors Common to Organizational Change 17 2 mins 5. … Identify errors common to organizational change. … Common Errors to Change (5 Minutes) Ask participants what some of the common errors are when trying … Compare the errors to those found presented on the slide that accompanies page 17. … Kotter identifies ways to institutionalize change and counter these errors.

209. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
     January 01, 2010 - While the IOM made recommendations to Congress for investigating medical errors and improving patient … The IOM noted that many of the errors in health care result from a culture and system that is fragmented … Later in 2000, under AHRQ leadership, that task force held a National Summit on Medical Errors and … these grants was to: • Explore different ways of reporting, analyzing, and using data on medical errors … While the Institute of Medicine made recommendations to Congress for investigating medical errors

210. Making Healthcare Safer IV | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/mhs4/index.html
     April 01, 2024 - I, II, and III have shown a positive impact of patient safety practices on the reduction of medical errors … evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors … evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors … Deprescribing Report Protocol Computerized Clinical Decision Support To Prevent Medication Errors

211. Adverse Events | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/topics/adverse-events.html
     Systems for Patient Safety Events Recent Research Studies Diagnostic errors … Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the … Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.

212. Adverse Drug Events (ADE) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/topics/adverse-drug-events-ade.html
     AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors in E.D. … Recent Research Studies Health literacy-informed communication to reduce discharge medication errors … Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory

213. Introduction | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-1.html
     September 01, 2020 - instance, checklists have been successful in preventing hospital-acquired infections 1 and preventing errors … surgical process. 2 The use of checklists has also been recommended as a tool to reduce diagnostic errors … . 3 Diagnostic errors are frequent and often have severe consequences 4 but have received little attention

214. AHRQ-Funded Patient Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie.pdf
     June 01, 2023 - medications at Brigham and Women’s Hospital resulted in fewer adverse drug events from dispensing errors … to improve patient safety by reducing harm and identification errors among patients … . ■ Reduce patient harms and errors within hospital settings (e.g., falls, adverse drug interactions, … The system identified many more errors than the previous manual process, thereby improving patient … Medication administration errors decreased, and few pump-related errors were made.

215. Diagnostic Safety Issue Briefs | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs.html
     March 01, 2024 - 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 … Pediatric Diagnostic Safety: State of the Science and Future Directions The Contribution of Diagnostic Errors

216. Efficiency Gains with Computerized Provider Order Entry (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-Steele_100.pdf
     March 18, 2008 - 0.0001 Discussion The single most studied benefit of CPOE has been the reduction in medication errors … in fewer callbacks for clarification; callbacks interrupt clinical workflow, potentially increase errors … Although much has been written about using CPOE to reduce medication errors,7, 8, 9 there is limited … Role of computerized physician order entry systems in facilitating medication errors. … Leapfrog responds to University of Pennsylvania study on CPOE errors.

217. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
     July 01, 2023 - In 1999, 44,000 to 99,000 people die from medical errors in hospitals each year. … Slide 4: How Can These Errors Happen? … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

218. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - Barriers to reporting near-miss errors include the additional workload burden imposed by a reporting … Factors that influence how students and residents learn from medical errors. … How surgeons disclose medical errors to patients: a study using standardized patients. … Lost opportunities: how physicians communicate about medical errors. … A preliminary taxonomy of medical errors in family practice.

219. Regulation of Health Policy: Patient Safety and the States (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - Errors may also exhibit characteristics of both omission and commission. … This is especially true of systemic errors. … Reducing medical errors. … Improving patient safety: what States can do about medical errors. … Patient safety and medical errors: a road map for State action.

220. Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
     April 01, 2021 - Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors . … Malpractice claims related to diagnostic errors in the hospital . BMJ Qual Saf. 2017;27(1). … Harried doctors can make diagnostic errors: they need time to think. … The Conversation  2016 Aug 22. https://theconversation.com/harried-doctors-can-make-diagnostic-errors-they-need-time-to-think … Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors .