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281. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.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 … Learning from patients’ experiences related to diagnostic errors is essential for progress in patient … Views of practicing physicians and the public on medical errors. … Americans’ Experiences With Medical Errors and Views on Patient Safety.

282. Patient Safety Executive Walkarounds (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Graham.pdf
     April 01, 2004 - high organizational priority, and (2) learn from direct care staff and physicians about near misses, errors … This culture must not only address strong accountability, but also must clinicians to report errors … The walkarounds have increased the reporting of actual errors and “near misses,” which has provided … ; it also is important to identify and report potential causes of errors before they occur. … In: Reducing medical errors and improving patient safety.

283. Clinical Pharmacists in Emergency Medicine (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-fairbanks_20.pdf
     February 21, 2008 - medication errors are a significant contributor to errors in the ED, as well as in the inpatient setting … to occur, and second, “absorb” errors that do occur. … Medication errors in emergency department settings – 5 year review [abstract]. … Patient concerns about medical errors in emergency departments. … Variables associated with medication errors in pediatric emergency medicine.

284. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (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-Maddox_111.pdf
     June 18, 2008 - ” PCA pumps with continuous respiratory monitoring and results achieved in significant programming errors … Numerous factors can lead to opioid-related RD: prescribing errors, PCA pump programming errors, “PCA … Part II: How to prevent errors. ISMP Medication Safety Alert; 2003 July 24. 4. … Part I: How errors occur. ISMP medication safety alert; 2003 July 10. … Design flaw predisposes Abbott Lifecare PCA Plus II pump to dangerous medication errors.

285. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - of ignorance and errors of implementation. … Errors of ignorance are due to inadequate knowledge, whereas errors of implementation occur during application … Cognitive error includes both errors of ignorance and implementation. … A structured teamwork system to reduce clinical errors. In: Spath PL, editor. … Safety errors in emergency medicine. In: Markovchick VJ, Pons PT, editors.

286. TeamSTEPPS Fundamentals Course: Module 1. Introduction | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/instructor/fundamentals/module1/igintro.html
     June 01, 2019 - Describe the impact of errors and why they occur. Describe the TeamSTEPPS framework. … How can we prevent medical errors? … Return to Contents Barriers to Team Performance Say: Errors can occur for many reasons, and … 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.

287. Introduction to the Fundamentals of TeamSTEPPS Concepts and Tools (Part 1 of 3)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps-webinar-071217.pptx
     January 01, 2017 - Describe the contributing factors to medical errors and the need for improved communication and teamwork … Medicine November 1999 “approximately 100,000 patients die in the hospital each year from medical errors … and 72% resulted from communication errors.” … by which government, health care providers, industry, and consumers can reduce preventable medical errors … IOM figure was probably underestimated: 210,000 – 440,000 deaths due to preventable medical errors May

288. FileNewTemplate
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module1.pptx
     March 01, 2010 - website. 2 Module Objectives After completing this module, you will be able to: Describe the impact of errors … Module 1: Introduction ‹#› After completing this module, you’ll be able to: Describe the impact of errors … occur and how to correct for these errors. … Lessons from the cockpit: How team training can reduce errors on L&D (Grand Rounds) Contemporary OB/Gyn … Module 1 Summary In this module you learned to: Describe the impact of errors and why they occur Describe

289. Presentation: Science of Improving Patient Safety and Identifying Defects
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
     December 01, 2017 - These skills are required for changes that will result in safer surgical care. 5 How Do These Errors … Errors also occur because systems frequently are not designed to catch mistakes before they reach the … Most errors DO NOT belong to individual doctors or nurses. … By accepting that people are not perfect, we are taking the first step toward realizing that medical errors … Science of safety training helps providers and others understand that the majority of errors arise from

290. Lessons in Safety Climate and Safety Practices from a California Hospital Consortium (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Singer.pdf
     April 01, 2003 - This heightened interest has increased pressure on hospitals to reduce medical errors. … Remember, implementation matters Medication errors received significant attention among consortium … are system errors, and not individual errors. … Residents’ suggestions for reducing errors in teaching hospitals. … In: Enhancing patient safety and reducing errors.

291. Identifying Barriers to the Success of a Reporting System (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
     March 01, 2004 - Studies have shown that many physicians are reluctant to participate in programs to report medical errors … collect patient safety information by providing care providers with the means to report events or errors … , care providers hold strong opinions of their own professional responsibilities to address errors. … , even errors related to close calls. … Physician and public opinions on quality of health care and the problem of medical errors.

292. Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems (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-Baker_107.pdf
     March 30, 2008 - Walsh and colleagues demonstrated that CPOE does introduce new kinds of errors in pediatric patients … , but they suggested that seriou computer-related errors are rare. … Committee on Identifying and Preventing Medication Errors. Preventing medication errors. … Role of computerized physician order entry systems in facilitating medication errors. … Medication errors related to computerized order entry for children.

293. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module1-presenters-notes.pdf
     January 12, 2022 - Diagnostic errors are a primary reason for medical liability claims. … It is not surprising, therefore, that errors in the process occur. … Appropriate communication can mitigate diagnostic errors. … Communication breakdowns and diagnostic errors: a radiology perspective. … Types of Diagnostic Error Where Do Diagnostic Errors Occur?

294. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/module1-introduction.pptx
     January 12, 2022 - Diagnostic errors are a primary reason for medical liability claims. … It is not surprising, therefore, that errors in the process occur. … Appropriate communication can mitigate diagnostic errors. … Catch errors that might have been made upstream.   … Communication breakdowns and diagnostic errors: a radiology perspective.

295. Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/publications/search.html
     January 01, 2024 - Diagnostic Safety Issue Brief #15 One of the best ways to collect information about diagnostic errors … 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

296. The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs (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-Jones_29.pdf
     February 23, 2008 - are viewed as the result of individual failure to one in which errors are viewed as opportunities to … improve the system.2 A voluntary reporting system that emphasizes learning from errors and improving … A commitment at the organizational level to detect and learn from errors. 3. … , and individual RCA of harmful errors) to support a learning culture. … In contrast, errors in nursing were described as “picking on individuals.”

297. Decision Support System Design and Implementation for Outpatient Prescribing: The Safety in Prescribing Study (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Feldstein.pdf
     January 01, 2004 - medication prescribing has been shown to be an effective method for reducing potential medication errors … Introduction The Institute of Medicine (IOM) report on medical errors identified computerization … One preliminary study5 examined the effect of basic computerized prescribing on medication errors in … as likely to be prevented with CPOE (including 43 percent of the potentially harmful errors). … Outline of SIP education content • Brief introduction to medical errors and SIP project.

298. Creating Safety in the Testing Process in Primary Care Offices (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-Elder_18.pdf
     February 19, 2008 - Testing represents a common arena for these types of errors. … associated with these events are common; 15 to 54 percent of primary care medical errors reported by … • Just culture: Reporting of issues, problems, events, and errors throughout the organization is … A preliminary taxonomy of medical errors in family practice. … The identification of medical errors by family physicians during outpatient visits.

299. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
     January 01, 2005 - Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot … Program 223 Identifying, Understanding, and Communicating Medical Device Use Errors: Observations … This typically occurs in organizations that have a “blaming” culture when errors occur. … Medical Device Errors—FDA Pilot Program 227 Further details about a report can be obtained through … Medical Device Errors—FDA Pilot Program 233 Author affiliations Center for Devices and Radiological

300. Tool: Check-Back (or Repeat-Back) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
     July 01, 2023 - Some misunderstandings lead to serious medical errors, including misdiagnoses. … The message may also be misunderstood because of typing errors or autocorrected spellings that change … What communication errors were avoided?