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341. 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.

342. Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician’s Office (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Galt.pdf
     April 23, 2004 - Medication errors in ambulatory care. … Impact of hand- held technologies on medication errors in primary care. … Research agenda: medical errors and patient safety. … Prescription-writing errors and markers: the value of knowing the diagnosis. … Patient counseling detects prescription errors.

343. Help Patients Take Medicine Correctly: Tool 16 | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/health-literacy/improve/precautions/tool16.html
     April 01, 2024 - increases the chances they will take the medicines they need to get and stay healthy and can reduce errors … Actions Prevent errors. … pill in the morning and 1 pill at bedtime" is unambiguous, whereas "Take twice daily" could lead to errors … If your EHR has an easy-to-use medicine reminder app, using it will reduce the chance of errors being

344. Appendix A. SIDM Competencies To Improve Diagnosis and Suggested Questions for Debriefing Case Studies | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html
     September 01, 2022 - continuous learning from analysis and discussion of excellent diagnostic performance, near-misses, and errors … How could your organization share the near-misses, errors, and excellent diagnostic performance from … Disclose diagnostic errors and missed opportunities transparently and in a timely manner to patients, … What problems or gaps do we have at our institution to prevent diagnostic errors like this from occurring

345. Slide 1 (ppt file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-100813.ppt
     January 01, 2013 - We have a just culture that disciplines based on risk taking People who work in teams make fewer errors … We are informed about errors that happen in this department. (C3) 3. … In this department, we discuss ways to prevent errors from happening again. … We are informed about errors that happen in this department. (C3) 57% 3. … In this department, we discuss ways to prevent errors from happening again.

346. Slide 1
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/module9/9_ts_office_mgmt.pptx
     January 20, 2006 - 1 05.2 Page ‹#› Page ‹#› RRS 1 Learning Objectives List Kotter’s Eight Steps of Change Identify errors … Management Activity (continued) Step 4: Review Kotter’s Eight Steps of Change (5 minutes) Step 5: Discuss errors … pressures for the next change ® TEAMSTEPPS 05.2 Mod 1 05.2 Page ‹#› Page ‹#› Office-Based Care Errors

347. AHRQ Hospital Survey on Patient Safety Culture: Items and Dimensions (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
     February 16, 2021 - Our procedures and systems are good at preventing errors from happening. A10. … We are informed about errors that happen in this unit. C5. … In this unit, we discuss ways to prevent errors from happening again. 7.

348. P-HIP Excel Tool Guidance (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/phip-mrabstraction-tool-guidance.pdf
     February 09, 2021 - P-HIP Calculate and save If you get all the way through data entry with no errors, you will see the … P-HIP Export errors If you get an error message similar to the one below, the Excel file had trouble … If the program finds the case and encounters no errors, you will be able to quickly page forward to … Abstraction Tool Navigation and Data Checks Branching Logic Stop -Replace Calculate and save Export errors

349. New Challenge Competition Offers Prizes for Ideas on Advancing AHRQ’s CDS Connect | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/881.html
     September 01, 2023 - Issue Brief Describes Strategies for Improving Clinician Psychological Safety in Reporting Diagnostic Errors … Issue Brief Describes Strategies for Improving Clinician Psychological Safety in Reporting Diagnostic Errors … describes strategies for improving clinician psychological safety in reporting and discussing diagnostic errors … The brief highlights specific barriers and challenges to reporting and learning from diagnostic errors

350. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
     May 01, 2023 - 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, … Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions … such as the use of tall man lettering in order to prevent such errors. 6. … Patient Safety Primer: Medication Errors and Adverse Drug Events 9.

351. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-7.html
     September 01, 2020 - Checklists to reduce diagnostic errors. Acad Med. 2011;86:307-313. … Patient safety strategies targeted at diagnostic errors: a systematic review. … Checklists to prevent diagnostic errors: a pilot randomized controlled trial.

352. TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/teamattitude.pdf
     March 21, 2014 - Teams that do not communicate effectively significantly increase their risk of committing errors. … Poor communication is the most common cause of reported errors. 27.

353. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
     August 01, 2022 - Slide 5 Say: Multiple studies have shown that involvement in medical errors and adverse events … Medical errors. Failure-to-rescue cases. First death experiences. … Say: 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

354. Advancing Patient Safety | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/advancing-patient-safety.html
     March 01, 2024 - safety findings, investigative approaches, process analyses, and practical tools for preventing medical errors … This compendium describes what federally funded programs have accomplished in understanding medical errors

355. Conclusions and Next Steps | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-5.html
     September 01, 2021 - Improving Diagnostic Safety and Quality in Healthcare The Contribution of Diagnostic Errors … Next Steps Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors

356. Hospital Survey on Patient Safety Culture: Background and Information for Translators (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
     September 01, 2009 - Our procedures and systems are good at preventing errors from happening. A10. … We are informed about errors that happen in this unit. C5. … In this unit, we discuss ways to prevent errors from happening again. 7. … Nonpunitive Response to Errors (More about this dimension: In a nonpunitive environment, when a mistake … Nonpunitive Response to Errors

357. Additional TeamSTEPPS Videos: Check-Back in Inpatient Surgical Teams | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps-program/resources/additional/check-back-team.html
     July 01, 2023 - instructions are described—and heard—correctly is an important safeguard against potential medication errors … part of an evidence-based approach to safer care, can improve communication and reduce the risk of errors

358. Well-Child Visits on the Rise, But Disturbing Gaps Remain for Underserved Populations | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/828.html
     August 01, 2022 - AHRQ Views Blog: AHRQ Expands Its Repertoire To Eliminate Diagnostic Errors . … AHRQ Views Blog: AHRQ Expands Its Repertoire To Eliminate Diagnostic Errors In a new blog post, AHRQ … An estimated 250,000 diagnostic errors occur annually in U.S. hospitals. … Defining and studying errors in surgical care: a systematic review .

359. Ldusafety Facguide (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
     May 01, 2017 - presentation, we will do the following: Describe the rationale for the use of checklists for reducing errors … Errors associated with schematic tasks are labeled “slips” and occur because of lapses in concentration … Errors associated with failures of attentional behavior are labeled “mistakes” and often occur because … Most errors in health care are slips rather than mistakes. … Checklist effectiveness for reducing errors can be enhanced when— they are created or adapted to meet

360. Voluntary Hospital Coalitions to Promote Patient Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rask.pdf
     January 01, 2004 - the planning stages well before the Institute of Medicine published its landmark report on medical errors … PHA provides both leadership and support for reducing errors pertinent information. … use (SMU) program The SMU program, which focuses on reducing the frequency of medication- related errors … , and develops an improvement plan for at least one of those errors. … PHA provides both leadership and support for reducing errors << /ASCII85EncodePages