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261. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
     July 14, 2023 - • EPC Program o Released the final report Diagnostic Errors in the Emergency Department: A Systematic … CDC • Division of Laboratory Systems o Health Equity and Diagnostic Errors: DLS envisioned and is … /grants/guide/rfa-files/RFA-HS-23-011.html https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency … /research https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency/research https:// … • Preventable Harm From Pediatric Outpatient Medication Errors: Measure Development o Project

262. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
     January 01, 2024 - Potential problems include medication errors, falls, infections, procedural complications, management … errors, diagnostic errors, lack of adequate monitoring, and lack of timely follow-up care. … human factors experts, and systems engineers—who developed an approach for investigating diagnostic errors

263. An Ambulatory Care Curriculum for Advancing 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/Mottur.pdf
     June 01, 2005 - The medication errors module, in turn, presents proven strategies to prevent the most common medication … errors by, for example, substituting computerized physician order entry systems for handwriting. … By recognizing what went wrong, physicians can avoid similar errors in the future. … Systems and medication errors modules received the highest approval rating from the audience. … Views of practicing physicians and the public on medical errors.

264. Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process (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-Dickerman_84.pdf
     June 04, 2008 - substantial evidence suggests that the design of hospital physical environments contributes to medical errors … A recent study correlated the relationship of medication errors to lighting levels. … As lighting intensity approaches 1,500 lux,7 the incidence of medication errors dramatically decreases … The Scope of the Problem Medical mistakes, or errors, in which the design of the physical environment … Illumination and errors in dispensing. Am J Hosp Pharm 1991; 48 2137-45. 8.

265. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
     January 01, 2019 - By the end of the workshop, participants should: • Be introduced to an understanding of why errors … 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, … Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans To Enhance Safety … The best practices are designed to help alert hospitals and focus their efforts on errors that cause

266. Taxonomic Guidance for Remedial Actions (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
     December 23, 2004 - Those that result from errors in the formation of the intent. 2. … While his study concerned speech, Norman acknowledged that the errors also applied to other activities … Knowledge-based errors can be due to information problems (information not being sought, information … being assumed, or failure to realize information is needed) or inference errors, when conditions or … Human errors. A taxonomy for describing human malfunction in industrial installations.

267. Understand the Science of Safety | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/understand/science-safety-slides.html
     July 01, 2018 - How Can These Errors Happen? Slide 6. The Science of Safety Slide 7. … an adverse event. 3, 4 44,000 to 99,000 people die in hospitals each year as the result of medical errors … line-associated blood stream infections per year. 8 Return to Contents   Slide 5: How Can These Errors … A look into the nature and causes of human errors in the intensive care unit. … http://www.ahrq.gov/research/findings/factsheets/errors-safety/haicusp/ . 9.

268. Fallpxtool3O (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3o.docx
     January 01, 2008 - 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

269. Appendix, MATCH Resources for Patients | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-12.html
     July 01, 2022 - Medication errors are the most common health care errors. … The Massachusetts Coalition for the Prevention of Medical Errors Massachusetts Coalition for the Prevention … of Medical Errors provides a formatted medication list that is a useful way to organize information

270. Safety Climate on Hospital Units: A New Measure (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
     January 01, 2004 - National Summit on Medical Errors and Patient Safety Research. … Research agenda: medical errors and patient safety. … Factors contributing to medication errors: a literature review. … Workload and environmental factors in hospital medication errors. … Perceived barriers in reporting medication administration errors.

271. Hospital Survey on Patient Safety Culture Version 2.0: Composites and Items (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
     August 01, 2019 - When staff make errors, this unit focuses on learning rather than blaming individuals. A13. … 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. C2. … When errors happen in this unit, we discuss ways to prevent them from happening again. C3.

272. Pediatric Diagnostic Safety Research and Initiatives Across the Care Continuum | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-3.html
     August 01, 2023 - pediatricians surveyed by the AAP Quality Improvement Innovations Network reported making diagnostic errors … at least monthly and errors that harmed patients at least annually. 61 Nearly 90 percent indicated … interest in reducing diagnostic errors, especially for conditions that evolve over months to years (e.g … have begun to address common MDOs through a quality improvement collaborative: Reducing Diagnostic Errors … Further, the reports also generated insights about where in the diagnostic process errors often occur

273. Hospital Survey Version 2.0: Background and Information for Translators | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/sops/international/hospital/translators-version-2.html
     September 01, 2023 - When staff make errors, this unit focuses on learning rather than blaming individuals. … More about this item: When staff make any errors or mistakes, supervisors/managers don’t immediately … 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. C2.  … When errors happen in this unit, we discuss ways to prevent them from happening again. C3. 

274. References (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/14-diagnostic-safety-toolkit-references.pdf
     November 24, 2020 - Types and origins of diagnostic errors in primary care settings. … Types and origins of diagnostic errors in primary care settings. … Uncharted territory: measuring costs of diagnostic errors outside the medical record. … Contextual errors and failures in individualizing patient care: A multicenter study. … Types and origins of diagnostic errors in primary care settings.

275. Appendix, Sample Letter to Discipline-Specific Leaders on Meeting Regarding Training and Implementation Strategy for Medication Reconciliation | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-8.html
     July 01, 2022 - [Insert Organization Logo Here] [Insert date] To [Insert Stakeholder] , Medication errors … are one of the highest single-volume sources of medical errors. … Unfortunately, many of these medication errors are associated with direct harm to patients.

276. Introduction | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-1.html
     September 01, 2021 - Improving Diagnostic Safety and Quality in Healthcare The Contribution of Diagnostic Errors … Introduction Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors … suggests it is imperative to focus on diagnostic safety in obstetrics to prevent and mitigate diagnostic errors

277. Introduction | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-2.html
     June 01, 2023 - 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 … We then extend this information to learning from safety events and diagnostic errors specifically.

278. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
     January 01, 2003 - One drawback of the IOM report is that its conclusions regarding the cost of medical errors were not … In all our GLM regressions, the robust standard errors were estimated using the Huber/White sandwich … Standard errors are in parentheses. **Significantly different from zero at the 99% level. … Standard errors are in parentheses. **Significantly different from zero at the 99% level. … In fact, we did not consider drug-related errors, diagnostic errors, and errors in choice of therapy

279. Tool 3J: Delirium Evaluation Bundle | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/delirium-evaluation.html
     January 01, 2013 - 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

280. AHRQ Issue Brief Outlines Competencies Needed To Improve Diagnostic Skills in Health Professions Education | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/806.html
     March 01, 2022 - Funding Opportunities for Research on Health Equity To Include Projects on Diagnostic Errors . … Funding Opportunities for Research on Health Equity To Include Projects on Diagnostic Errors Research … proposals aimed at preventing diagnostic errors are among those being solicited by AHRQ in a recent … is funding large patient safety research projects (RO1) that identify strategies to reduce medical errors