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2141. Create a Safe Medicine List Together (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-slides-508.pdf
      April 10, 2018 - That’s at least 160 million errors. … In the primary care setting, medication safety issues include prescribing errors, contraindications, … • Results in a complete and accurate medicine list • Reduces medicine errors • Offers the opportunity … One clinician observed, “It closes the gaps, reduces medication errors, offers the opportunity to reduce

2142. Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Seger.pdf
      January 01, 2003 - Phillips et al.1 have estimated that as many as 7,000 people die each year due to medication errors … Medication errors that caused an injury were called preventable ADEs. … Medication errors that had potential to cause injury were called potential ADEs.12 We also noted some … medication errors that we felt had little chance of causing harm, but still represented an error in … Relationship between medication errors and adverse drug events.

2143. Issue Brief 9: Improved Diagnostic Accuracy Through Probability-Based Diagnosis (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-probabilistic-thinking.pdf
      September 01, 2022 - 1 e Introduction Errors … Most patients will experience diagnostic errors in their lifetime.1 Many diagnostic errors result from … probability.3 Thus, more accurate execution of probability- based diagnosis is needed to reduce diagnostic errors … Errors in estimating probability of disease may arise from this approach19 as mathematical calculations … clinician management of probability will lead to better management of patients and fewer diagnostic errors

2144. TeamSTEPPS Teamwork Performance Observation Tool (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-team-performance-tool.pdf
      May 31, 2023 - Monitors fellow team members to ensure safety and prevent errors c.

2145. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
      May 01, 2016 - , were a contributing factor in 14 percent of errors in the sample. … improvements to prevent similar errors in the future” (Corbett et al., 2013). … , were a contributing factor in 14 percent of errors in the sample. … The researchers also learned through the project that the taxonomy used to classify errors could be … Improving patient safety and restructuring medical liability using ACEs: Medication errors.

2146. Primary Care Practice Facilitation Curriculum Module 8: Approaches to Quality Improvement (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-8-approaches-to-qi.pdf
      September 01, 2015 - evolution from quality assurance, where the emphasis was on inspection and punishment for medical errors … myth Fallibility recognized Solo practitioners Teamwork Peer review ignored Peer review valued Errors … punished Errors seen as opportunities for learning This evolution to a QI framework began in earnest … brought to the public’s attention the fact that 44,000 to 98,000 deaths occur each year due to medical errors … If variation is reduced, there is no need for inspection since defects (errors) will be reduced or eliminated

2147. Improving Communication and Teamwork in the Surgical Environment
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement/pf-engagement-slide-set.pptx
      May 01, 2017 - members5— Generally assume that most care is safe and that there are system checks to prevent medical errors … Blame provider, not system, for medical errors Underestimate medical errors Patient and family engagement … in health care may decrease medical errors by allowing patients and family to— Be informed, asking questions … about and participating in their care Help prevent specific safety events and/or medical errors Report

2148. Hospital Survey on Patient Safety (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
      December 22, 2017 - Our procedures and systems are good at preventing errors from happening .......................... … We are informed about errors that happen in this unit .............................. … In this unit, we discuss ways to prevent errors from happening again ...... 1 2 3 4 5 6.

2149. AHRQ Safety Program for Perinatal Care: Implement Teamwork and Communication
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement.pptx
      May 01, 2017 - Were errors made or avoided? Are resources available? … communication influence the outcomes of the unit team Research supports the connection between communication errors … Department of Health and Human Services makes no warranties regarding errors or omissions and assumes

2150. Hospital Survey on Patient Safety (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
      June 09, 2016 - Our procedures and systems are good at preventing errors from happening (1 (2 (3 (4 (5 SECTION … We are informed about errors that happen in this unit (1 (2 (3 (4 (5 4. … In this unit, we discuss ways to prevent errors from happening again (1 (2 (3 (4 (5 6.

2151. SITUATION MONITORING
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module1/1_ts_office_intro-ig.pptx
      January 20, 2006 - Department of Defense strive to optimize the lessons learned from multiple initiatives focused on reducing errors … environment; and Have a shared understanding of how a procedure should happen in order to identify when errors … occur and how to correct for these errors.

2152. Hospital Survey on Patient Safety (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
      March 22, 2017 - Our procedures and systems are good at preventing errors from happening .......................... … We are informed about errors that happen in this unit .............................. … In this unit, we discuss ways to prevent errors from happening again ...... 1 2 3 4 5 6.

2153. Fall Prevention Toolkit (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_tools.docx
      January 01, 2012 - Total Errors: _______ SCORING*: 0-2 errors: normal mental functioning 3-4 errors: mild cognitive impairment … 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment *One more … Total Errors: _______ SCORING*: 0-2 errors: normal mental functioning 3-4 errors: mild cognitive impairment … 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment * One more

2154. TeamSTEPPS 2.0 Overview (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/ts2-0ltc_overview.pdf
      April 24, 2017 - essential for the provision of quality health care and for the prevention and mitigation of medical errors … TeamSTEPPS promotes the effectiveness of teams and team performance to reduce the likelihood of medical errors

2155. Module 8 Instructor Slides (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module8/ts2-0ltc_module8_slides_chmgmt.pdf
      July 11, 2017 - 8 LTC 2.0 Page 2 Change Management Objectives • List the Eight Steps of Change • Identify errors … Mod 8 LTC 2.0 Page 12 Change Management Errors Common to Organizational Change • Allowing for

2156. TeamSTEPPS® for Office-Based Care - Course Evaluation (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/handouts/courseeval.pdf
      December 02, 2015 - Describe the impact of errors and why they occur .................................................... … Identify errors common to organizational change......................................................

2157. The PeaceHealth Ambulatory Medication Safety Culture Survey (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stock_72.pdf
      January 01, 2007 - - thirds of office visits concluding with a prescription for medication.1 The risks for medication errors … health care organizations improve patient safety culture.3 In their report, Preventing Medication Errors … Medication errors are handled appropriately in this clinic. 3. … patient in this clinic (not my patient) I would have no concern at all about possible medication errors … Preventing medication errors. Institute of Medicine.

2158. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Johnson_90.pdf
      June 10, 2008 - Patient safety is a good entry point into SBP because the concepts of safety, errors, and harm all place … • Participate in identifying system errors and implementing potential systems solutions. … Individuals in an organization must feel empowered to report errors, while organization leaders must … implement ways to discover errors and make process improvements to reduce error. … Human errors: Their causes and reduction. In: Bogner MS, ed. Human error in medicine.

2159. AHRQ Safety Program for Perinatal Care: Board Checklist (doc file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/board-checklist.docx
      May 01, 2017 - Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that

2160. TeamSTEPPS 2.0: Introduction (pdf file)
      ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/introduction.pdf
      February 28, 2014 - essential for the provision of quality health care and for the prevention and mitigation of medical errors