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361. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
     April 22, 2004 - Alper Abstract Many articles in the medical literature state that medical errors are the result of … From this perspective, all medical errors and adverse events are somebody’s fault. … This fork was inspired by research that uncovered a disturbing numbers of errors in health care.10, … Medication errors observed in 36 health care facilities. … Medication errors and pediatric inpatients. JAMA 2001 Apr;285(16):2114–20. 27.

362. Envisioning Patient Safety in the Year 2025: Eight Perspectives (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-Henriksen_104.pdf
     July 30, 2008 - The environment is nonpunitive for errors, which are seen as opportunities for learning, but intolerant … When errors do occur, our pride leads us to respond with surprise (This should never happen here!) … Stress exacerbates all known clinical conditions, increases staff fatigue, and contributes to errors … Also, in the event of medical error, patients and family members will be able to report errors to a … Semi-intelligent software in electromedical devices has reduced errors and enhanced user skill.

363. Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences (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-Devine_83.pdf
     April 06, 2008 - quality of care; computerized provider order entry (CPOE) systems are believed to reduce medication errors … systems and introduces unpredicted and unintended consequences, including the generation of new types of errors … , thus minimizing the occurrence of prescription-related medication errors. … Generation of new kinds of errors. 8. Changes in the power structure. 9. … Role of computerized physician order entry systems in facilitating medication errors.

364. Improving Your Laboratory Testing Process Toolkit (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
     December 01, 2017 - Errors in managing tests are more common than most of us realize. … Addressing the system can reduce errors. Figure 1. … Medical testing errors in this office do not harm patients. 9. … Providers and staff openly discuss causes and effects of errors. 10. … Reduce errors in delayed notification of lab results.

365. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-pfe.pdf
     January 01, 2023 - Patient reporting of medical errors and near misses; 2. … Key Findings/Impact: Among patients with errors at baseline, 59.3 percent of errors were resolved by … errors of omission (failure to intensify therapy when indicated) (p > 0.05). … and rated likelihood of medical errors. … Most recommended actions for preventing medical errors were viewed as effective.

366. Hospital Survey on Patient Safety Culture Version 2.0 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
     January 01, 2021 - When staff make errors, this unit focuses on learning rather than blaming individuals........... 1 … 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 ............................................ … When errors happen in this unit, we discuss ways to prevent them from happening again .. 1 2 3 4

367. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-111921.pdf
     March 11, 2022 - Diagnostic Safety Capacity Building Contract: o An issue brief titled The Contribution of Diagnostic Errors … Agency Update o The Evidence-based Practice Center Program draft report Diagnostic Errors

368. 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

369. TeamSTEPPS Teamwork Attitude Questionnaire (T-Taq) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/sitetools/ts2-0ltc_teamwork_attitudes_ques.pdf
     April 24, 2017 - Teams that do not communicate effectively significantly increase their risk of committing errors. … Poor communication is the most common cause of reported errors. 27.

370. TeamSTEPPS® for Office-Based Care - TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/handouts/teamattitude.pdf
     December 09, 2015 - Teams that do not communicate effectively significantly increase their risk of committing errors. … Poor communication is the most common cause of reported errors. 27.

371. AHRQ-Funded Patient Safety Research Featured in Health Affairs | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/healthaffairs.html
     March 01, 2019 - commitment to lead patient-safety efforts nationwide, AHRQ has funded studies that aim to reduce medication errors … improve communication strategies that support better care coordination, and lower the rate of diagnostic errors

372. Conclusion | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
     August 01, 2022 - Thus, it is no wonder that diagnostic errors occur. … of distributed cognition would be a major advance in the quest to limit harm associated with these errors

373. 10 Patient Safety Tips for Hospitals (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/10-tips-for-hospitals.pdf
     December 01, 2009 - for Healthcare Research and Quality PATIENT SAFETY 10 Patient Safety Tips for Hospitals Medical errors … patient safety information with Patient Safety Organizations (PSOs) to help others avoid preventable errors … Prevent medication errors by offering pharmacists well-lit, quiet, private spaces so they can fill prescriptions

374. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/references.html
     July 01, 2022 - Medications At Transitions and Clinical Handoffs (MATCH) Study: an analysis of medication reconciliation errors … Preventing Medication Errors: Quality Chasm Series , 2006. … http://iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx .

375. PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-slides-final508.pptx
     April 12, 2018 - breakdowns within the healthcare team or between the team and the patient or family can result in medical errors … communication both with the patient and among the healthcare team Makes communication more efficient Prevents errors … Miscommunication and omissions can lead to medical errors and adverse events. … A Warm Handoff Plus can help close the communication gaps and prevent errors.

376. Hospital Survey on Patient Safety Culture Version 2.0 (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-English-05.18.21.docx
     June 09, 2016 - When staff make errors, this unit focuses on learning rather than blaming individuals 1 2 3 4 … In this unit, there is a lack of support for staff involved in patient safety errors 1 2 3 4 5 … We are informed about errors that happen in this unit 1 2 3 4 5 9 2. … When errors happen in this unit, we discuss ways to prevent them from happening again 1 2 3 4 5

377. About the Toolkit Development | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
     July 01, 2023 - addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication errors … High-reliability systems and a culture of learning from errors (or near misses) are needed to minimize

378. Results | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/results.html
     March 01, 2017 - threats to patient safety in primary care settings: breakdowns in communication, medication-related errors … Patient Safety in Primary Care Theme Threats to Patient Safety Communication Documentation errors … for followup and expectations Not enough time with patients Medication issues Prescribing errors … been identified as an important method of enhancing communication, a vehicle to identify potential errors … Two articles (2.1%) addressed diagnostic errors.

379. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
     September 01, 2016 - for health care organizations as they strive to eliminate the factors that contribute to medical errors … to moving toward a safer health system is changing the culture from one of blaming individuals for errors … to one in which errors are treated not as personal failures, but as opportunities to improve the system … assessment, health care organizations can assess staff attitudes about patient safety issues, medical errors … evaluated the initiative of Second Victim Experience support for clinicians who have made medical errors

380. TeamSTEPPS for Office-Based Care: Change Management | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/officebasedcare/module9/office_mgmt.html
     September 01, 2015 - Act Slide 11: Produce Short-Term Wins Slide 12: Don’t Let Up Slide 13: Create a New Culture Slide 14: Errors … Identify errors common to organizational change. … Activity (continued) Step 4: Review Kotter’s Eight Steps of Change (5 minutes) Step 5: Discuss errors … Return to Contents Slide 14: Errors Common to Organizational Change Allowing for complacency.