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321. Learn About CUSP | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/learn/sl-cusp.html
     December 01, 2012 - Examples of Defects or Errors That Affect Patient Safety Slide 25. … Review the impact of errors and patient harm and the underlying causes of errors. … Identify Defects Through Sensemaking Introduce CUSP and Sensemaking tools to identify defects and errors … Examples of Defects or Errors That Affect Patient Safety   Defect Intervention Unstable oxygen … Communication is cited as a root cause of most errors.

322. Tool 3O: Postfall Assessment for Root Cause Analysis | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/root-cause.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

323. Resource List - AHRQ Hospital Survey (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
     April 01, 2023 - Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans To Enhance Safety … It makes the case that true transparency will result in improved outcomes, fewer medical errors, more … This article lists 10 tools to assist in better patient handoff communications and to avoid errors. … The best practices are designed to help alert hospitals and focus their efforts on errors that cause … Patient Safety Primer: Medication Errors and Adverse Drug Events 23.

324. TeamSTEPPS 2.0 Module 1: Introduction
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule1.pptx
     January 01, 2011 - How can we prevent medical errors? Can something similar happen in our organization? … Think about some ways we prevent medical errors. … How can we prevent medical errors? Can something similar happen in our organization? … or preventing errors. … There's a lot of information here on the history of medical errors and patient safety.

325. TeamSTEPPS, Module 8: Change Management (Instructor Guide) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module8/igchangemgmt.pdf
     February 25, 2014 - CHANGE MANAGEMENT: HOW TO ACHIEVE A CULTURE OF SAFETY SUBSECTIONS • Eight Steps of Change • Errors … Errors Common to Organizational Change 17 2 mins 5. … COMMON ERRORS TO CHANGE (5 Minutes) 1. … Compare the errors to those found presented on the slide that accompanies page 17. … Kotter identifies ways to institutionalize change and counter these errors.

326. Using the AHRQ Pharmacy Survey on Patient Safety Culture (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/cousins_introslides.pdf
     October 29, 2013 - Safety in Community Pharmacies More than 61,000 Community Pharmacies (2011) One estimate found 4 errors … Medication Dispensing Errors in Community Pharmacies: A Nationwide Study 8 8 Technical Expert

327. Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/studies/index.html?page=479
     January 01, 2024 - Low-Income (171) Maternal Care (182) Medicaid (359) Medical Devices (71) Medical Errors … Telemedicine consultations and medication errors in rural emergency departments. … Keywords: Children/Adolescents, Medical Errors, Medication, Rural Health, Telehealth Abramson … Use of e-prescribing resulted in relatively low error rates (6.0 errors per 100 prescriptions). … These rates were sustained over time but without further improvement (6.0 versus 4.5 errors per 100)

328. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
     August 01, 2022 - Slide 7 Say: It is important to understand the distinction between events and errors when an … 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.

329. Change Management (Instructor Guide) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module8/ts2-0ltc_module8_ig_chmgmt.pdf
     June 09, 2017 - CHANGE MANAGEMENT: HOW TO ACHIEVE A CULTURE OF SAFETY SUBSECTIONS • Eight Steps of Change • Errors … Errors Common to Organizational Change 17 2 mins 5. … COMMON ERRORS TO CHANGE (5 Minutes) 1. … Compare the errors to those found presented on the slide that accompanies page 17. … Kotter identifies ways to institutionalize change and counter these errors.

330. A Process-centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Akins.pdf
     January 01, 2003 - occur as the result of a chain of errors within a faulty system that is not designed to detect errors … Evaluating medical errors. JONA 1986:16 (4);41–4. 22. Ernst MA, Buchanan A, Cox C. … A judgment of errors. Nurs Times 1991:87(14);26–30. 23. Lilley LL, Guanci R. … CQI case study: reducing medication errors. Jt Comm J Qual Improv 1995;21 (5):232–7. 37. … Incidence and acceptance of errors in medicine.

331. PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
     May 01, 2011 - Scenarios for second-victims: Patient or family “connects” with staff member Pediatric cases Medical errors … Module 6 7 As referenced in Module 3, this diagram shows the distinction between adverse events and errors … , and recognizes that not all adverse events are medical errors, and not all medical errors are adverse … Therefore, it is important to recognize the distinction between medical errors and adverse events, as … AHRQ Primer: Support for Clinicians Involved in Errors and Adverse Events (Second Victims) Wachter RM

332. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-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 … Types and origins of diagnostic errors in primary care settings. … Americans’ Experiences With Medical Errors and Views on Patient Safety.

333. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
     September 01, 2022 - Cross-Cutting: Health Information Technology Cross-Cutting: Other Topics Delirium Diagnostic Errors … Infection Control: Urinary Tract Infection Patient and Family Engagement Patient Identification Errors … Patients Summary of Evidence (Not reviewed) (Not reviewed) Fatigue, Sleepiness, and Medical Errors …   MHS I (2001) MHS II (2013) MHS III (2020) Patient Safety Practices Targeted at Diagnostic Errors … Radiological Patient Safety Practices  MHS I (2001) MHS II (2013) MHS III (2020) Reducing Errors

334. TeamSTEPPS Module 1: Introduction (Instructor Guide) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module1/igintro-cx062819.pdf
     January 01, 2007 - will be able to: • Describe the TeamSTEPPS Master Trainer course; • Describe the impact of errors … • How can we prevent medical errors? … 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. … Finally, your team will be safer, allowing the team to more readily identify and correct errors, if

335. TeamSTEPPS Module 1: Introduction (Instructor Guide) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module1/igintro.pdf
     January 01, 2007 - will be able to: • Describe the TeamSTEPPS Master Trainer course; • Describe the impact of errors … • How can we prevent medical errors? … 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. … Finally, your team will be safer, allowing the team to more readily identify and correct errors, if

336. Connecting the Dots: Improving Unit Safety Culture to Stop HAI | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cauti-tools/archived-webinars/connecting-dots-slides.html
     December 01, 2017 - shared, learned 1 beliefs and behaviors that reflect an organization’s willingness to learn from errors … We have a just culture that disciplines based on risk taking People who work in teams make fewer errors … (sharp end) Latent errors Just Culture and behavior 17-19 : Conduct: human error, negligence … We are informed about errors that happen in this department. 57% 3. … In this department, we discuss ways to prevent errors from happening again. 59% Slide 37 Learning

337. Building Self-Empowered Teams for Improving Safety in Postoperative Pain Management (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-Singh-R_68.pdf
     April 20, 2008 - is the lack of awareness of the type, incidence, and consequences of these errors. … Bates and colleagues have described the difficulties involved in defining and quantifying errors. … • Avoidance of individual blame when errors occur – To Err Is Human. … • The importance of focusing on team learning from errors. … Reducing the frequency of errors in medicine using information technology.

338. Improving Patient Safety Using ATHENA-Decision Support System Technology: The Opioid Therapy for Chronic Pain Experience (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-Michel_92.pdf
     April 30, 2008 - Introducing information technology can, however, create unforeseen errors.4 For example, a study by … this order entry system increased workload on the health care team and raised the likelihood of new errors … In order to improve patient safety with a decision support system and prevent errors resulting from … Reducing Risk of Prescription Errors To reduce risk for prescription errors, two tools have been provided … Patients may also be harmed by errors in dosing calculations when physicians attempt to switch a patient

339. Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
     January 01, 2004 - A study of the ethical duty of physicians to disclose errors. … Medication errors: the nursing experience. Albany, NY: Delmar Publishers, Inc.; 1994. 10. … Patients’ and physicians’ attitudes regarding the disclosure of medical errors. … Disclosing medical errors: practical, ethical and legal considerations. … Health plan members’ views about disclosure of medical errors.

340. The Rural Physician Peer Review Model©: A Virtual Solution (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-Williams_115.pdf
     June 19, 2008 - errors, when it is medically difficult to make an accurate diagnosis; (2) system errors; and (3) cognitive … errors, which are caused by a physician’s cognitive deficits. … The Rural Physician Peer Review Model seeks to address system errors and cognitive errors. … Toward a cognitive taxonomy of medical errors. … A preliminary taxonomy of errors in family practice.