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301. Table of Contents: Volume 1. Assessment (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
     December 22, 2008 - The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis … Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology Martin November, … Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS … xv Using Data Mining to Predict Errors in Chronic Disease Care Ryan M. … xviii Using Home Visits to Understand Medication Errors in Children Kathleen E.

302. Table of Contents: Volume 4. Technology and 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/TableofContents_Vol4.pdf
     December 22, 2008 - Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study John Lynch … viii Using Home Visits to Understand Medication Errors in Children Kathleen E. … The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis … Neuspiel, Margo Guzman, Cari Harewood Relationship Between Patient Harm and Reported Medical Errors … xvii Using Data Mining to Predict Errors in Chronic Disease Care Ryan M.

303. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
     August 01, 2022 - Thus, it is no wonder that diagnostic errors occur. … Diagnostic Errors in the Emergency Department: A Sys- tematic Review. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Changes in medi- cal errors after implementation of a handoff program. … The importance of cognitive errors in diagnosis and strategies to minimize them.

304. Appendix A | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-apa.html
     April 01, 2018 - Root Cause Analysis (RCA) '10 Patient Safety Tips for Hospitals' '20 Tips to Help Prevent Medical Errors … in Children' '20 Tips to Help Prevent Medical Errors: Patient Fact Sheet' '30 Safe Practices for … Ventilator-Associated Pneumonia' 'Reducing Discrepancies in Medication Orders' 'Reducing Medical Errors … Transforming Hospitals: Designing for Safety and Quality' 'Ways You Can Help Your Family Prevent Medical Errors

305. Appendix D. Organizations and Web Sites | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/appd.html
     March 01, 2017 - Patient Safety Maryland Patient Safety Center Massachusetts Coalition for the Prevention of Medical Errors … Council—Calgary, Alberta Patients are Powerful Patients.About.Com Persons United Limiting Sub standards and Errors … in Health Care Persons United Limiting Sub standards and Errors of America Persons United Limiting … Sub standards and Errors of NY Picker Institute Picker Institute Europe Planetree Quality and

306. TeamSTEPPS 2.0 Module 8: Change Management
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule8.pptx
     March 28, 2006 - After completing this module, you'll be able to list the eight steps of change, identify errors common … Practices Step 3: Prioritize Best Practices Step 4: Review Kotter’s 8 Steps of Change Step 5: Common Errors … And then step five, common errors. … Discuss what some of the common errors are when trying to make an organizational change. … listed on the following slide. 18 Errors Common to Organizational Change (Slide 12) Common errors:

307. Background and Information for Translators of the AHRQ Hospital Survey on Pateint Safety Culture Version 2.0 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/sops-hsops-2-translation-guidelines.pdf
     August 01, 2023 - When staff make errors, this unit focuses on learning rather than blaming individuals. … In this unit, there is a lack of support for staff involved in patient safety errors. … (negatively worded) • More about this item: When staff are involved with patient safety errors, there … 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.

308. Making Healthcare Safer III: Executive Summary | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/mhs3/exe-summary.html
     March 01, 2020 - Diagnostic Error: Peer Review Diagnostic errors Diagnostic discrepancy rates 14 studies; … Nonrandom peer review appears to be more effective at identifying diagnostic errors than random peer … Diagnostic Error: Education and Training Diagnostic accuracy Diagnostic errors Cognitive biases … Patient Identification Errors: Patient Identification Errors in the Operating Room Compliance … The harms include diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant

309. Reinforcing the Value and Roles of Nurses in Diagnostic Safety - Issue Brief (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/nurse-role-dxsafety.pdf
     September 02, 2022 - AHRQ Publication No. 22-0026-4-EF. 1 e Introduction Diagnostic errors are common and costly, … Nurses are key in preventing deadly diagnostic errors in cardiovascular diseases. … Diagnosis is a team sport - partnering with allied health professionals to reduce diagnostic errors. … Diagnostic error: safe and effective communication to prevent diagnostic errors. … Communication breakdowns and diagnostic errors: a radiology perspective.

310. Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/medlist.html
     October 01, 2022 - strategy helps to improve documentation because we can see the medications and decrease medication errors … In the primary care setting, medication safety issues include prescribing errors, contraindications, … That’s at least 160 million medication errors annually .

311. AHRQ's Quality & Patient Safety Programs by Setting: Ambulatory Care | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/ambulatory/index.html
     July 01, 2022 - Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit  aims to assist primary care practice teams … with a systematic approach to reduce diagnostic errors among children in three important areas: Elevated … Ambulatory Settings is designed to help staff actively engage patients and their care partners to prevent errors

312. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/corbett.html
     August 01, 2017 - Increasingly, inpatient medication risk management efforts focus on preventing errors by improving systems … the potential for patient harm and increased medical liability due to medication discrepancies and errors … to one-third were preventable. 16 Patients at high risk to experience medication discrepancies and errors … When errors that result in harm occur, full disclosure is the best practice. … Patients’ and physicians’ attitudes regarding the disclosure of medical errors.

313. Communication and Optimal Resolution (CANDOR) Toolkit Module 3: Preparing for Implementation: Change Readiness and Gap Analysis
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
     August 25, 2015 - McGraw Hill Medical, 2012. 8 It is important to understand the distinction between events and errors … Errors are defined as an act of commission (doing something wrong) or omission (failing to do the right … The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … and errors that are not adverse events. 8 Develop a Measurement Strategy5 WHAT to measure Process,

314. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (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-Faltz_56.pdf
     March 27, 2008 - NYPORTS provides useful information about systems errors and effectiveness of prevention strategies. … These errors occurred in a wide variety of locations (Table 3). Table 3. … Some intraoperative errors were reported under this code (e.g., wrong segment of colon connected to … Of the 20 Code 912 errors in bedside procedures, eight were chest-tube cases (two wrong patient, six … Discussion According to the National Quality Forum (NQF), “never events” are “errors in medical care

315. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
     August 01, 2022 - Ask: How would you describe the organization's culture relative to blame or responsibility for errors … A Just Culture supports disclosure and learning from errors and encourages viewing every event as an … Human errors are abundant and inevitably repeated when system processes are not corrected or adjusted … Only then can we learn why errors were truly made, and how we can implement policy, process, and improvement … mechanisms to prevent the same errors from happening again.

316. Diagnostic Safety Resource List (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
     May 01, 2023 - It thus potentially prevents diagnostic errors by preventing patients from “falling through the cracks … Each guide provides foundational education about diagnostic errors and tangible ideas and suggestions … It highlights bright spots: organizations that use a Just Culture approach to investigating errors, … Harnessing Improvement to Reduce Diagnostic Errors and Delays (Podcast) http://www.ihi.org/resources … Harnessing Improvement to Reduce Diagnostic Errors and Delays (Podcast) 4.

317. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
     April 09, 2004 - The pervasive focus on medical errors in the U.S. health care system gained momentum in 1991, when a … Reporting Program [MER]; MEDMARxSM, a national database for medication errors). … Federal Actions to reduce medical errors and their impact; 2000 Feb. 5. Flowers L, Riley T. … State-based mandatory reporting of medical errors. … The Institute of Medicine report on medical errors: could it do harm?

318. Appendix E. Category Definitions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/appe.html
     March 01, 2017 - Diagnostic errors, management of test results Definition: Errors in diagnosis, medication, and communication … Reporting such errors is critical to ensuring patient safety and provider accountability.

319. Development and Implementation of The University of Texas Close Call Reporting System (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Martin.pdf
     March 01, 2004 - Texas Close Call Reporting System, an anonymous tool used to collect information about potential errors … and close calls.3–7 Asking health care providers to report errors and close calls is an excellent way … First, given that close calls are believed to have underlying causes similar to those for errors,11, … as opposed to actual errors. … Errors, incidents and accidents in anaesthetic practice.

320. Chapter 1. Environmental Scan | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program1.html
     April 01, 2018 - Research and Quality (AHRQ, via http://psnet.ahrq.gov/glossary.aspx ) The prevention of health care errors … and elimination or mitigation of patient injury caused by health care errors. … and maximize the likelihood of intercepting errors when they occur. … These events include "errors," "deviations," and "accidents.” … Patient safety efforts aim to reduce errors of commission or omission.