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381. Nurses’ Roles in the Diagnostic Process | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety2.html
     September 01, 2022 - recently convened expert panel further stressed the value of a team-based approach to reducing diagnostic errors … 12 Nurses are key members of this team-based approach and well positioned to help reduce diagnostic errors

382. AHRQ Research Summit on Improving Diagnosis in Health Care | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety.html
     April 01, 2019 - These errors occur in all settings of care, contribute to about 10 percent of patient deaths, and are … Substantial effort is needed to identify research priorities, including how to measure and reduce diagnostic errors

383. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/brock.html
     August 01, 2017 - The first component aimed to reduce medical errors by improving team communication through adoption of … Patients' and physicians' attitudes regarding the disclosure of medical errors. … Risk managers, physicians, and disclosure of harmful medical errors. … Choosing your words carefully: how physicians would disclose harmful medical errors to patients. … U.S. and Canadian physicians' attitudes and experiences regarding disclosing errors to patients.

384. TeamSTEPPS for Office-Based Care: Change Management | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps/officebasedcare/module9/office_mgmt-ig.html
     September 01, 2015 - Identify errors common to organizational change. … Errors Common to Change (5 Minutes): Ask participants what some of the common errors are when trying … Compare the errors to those found on slide 14 that accompanies page 14. … Return to Contents Errors Common to Organizational Change Say: Training is not a standalone … Kotter identifies ways to institutionalize change and counter these errors.

385. Implementation Change Management | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/teamstepps-program/curriculum/implement/activity/change.html
     June 01, 2023 - Identify errors common to organizational change. … Harms elsewhere may be invisible to those who caused them (e.g., diagnostic errors subsequently discovered … Errors Common in Organizational Change If a culture of safety is not constantly reinforced, other emphases … Avoiding this error and other errors is key to achieving the culture of safety TeamSTEPPS promotes. … Other common errors include: Allowing complacency.

386. Introduction | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-1.html
     August 01, 2023 - Research Conclusion References Pediatric clinicians self-report making diagnostic errors … that missed diagnostic opportunities (MDOs) constituted the greatest proportion of care management errors

387. 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.

388. Learn about CUSP | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/learn/index.html
     July 01, 2018 - Discusses the effects of errors and patient harm and the underlying causes of errors.

389. 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

390. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-110620.pdf
     March 11, 2021 - • Preventable Harm From Pediatric Outpatient Medication Errors: Measure Development: This project … The discussion included topic-specific comments around diagnostic errors related to health information

391. 2019 Hospital Survey Pilot Test Results Part II (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pilot-test-partii.pdf
     September 01, 2019 - We are informed about errors that happen in this unit. … We are informed about errors that happen in this unit. … We are informed about errors that happen in this unit. (C1) 64% 71% 2. … 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. (C1) 71% 65% 65% 65% 2.

392. Summary of Patient Safety Research Opportunities | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/news-events/summit-research-2020/questions.html
     March 01, 2021 - Health and Systemic Racism on Patient Safety Understanding and Reducing Harm caused by Diagnostic Errors … Understanding and Reducing Harm caused by Diagnostic Errors How are diagnostic errors within and across … For example, do successful safety practices in the hospital setting also reduce medication errors when … Medical errors, inconsistent practices, and variable outcomes of care still affect patient confidence … approaches help senior administrative leaders understand the effects of their decisions on safety and errors

393. Patient Safety Tools | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
     June 01, 2022 - The strategies can help prevent harmful events such as medication errors, bed sores, and healthcare-associated … Guide for Hospitals focuses on how hospitals can better identify, report, monitor, and prevent medical errors … journal and forum on patient safety and health care quality that features expert analysis of medical errors … describe accomplishments between 1999 and 2004 by federally funded programs in understanding medical errors … Web: [ in English ] Web: [ en español ] 20 Tips to Help Prevent Medical Errors tells patients

394. Co-producing a Diagnosis
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/09-diagnostic-safety-practice-orientation.pptx
     November 24, 2020 - Diagnostic Safety Practice Orientation AHRQ Publication No. 21-0047-8-EF August 2021 1 Diagnostic Errors … In primary care settings, nearly 79 percent of the errors in diagnosis happen within the patient-provider … patient and provider engagement in the diagnostic process are needed to reduce the risk of diagnostic errors … Types and origins of diagnostic errors in primary care settings. … Learning from patients’ experiences related to diagnostic errors is essential for progress in patient

395. Appendix F. Interventions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/appf.html
     March 01, 2017 - Diagnostic error: safe and effective communication to prevent diagnostic errors No Yes … of diagnostic errors in primary care. … Recommendations to identify errors. … patients and providers to avoid medication errors in practice. … Speak Up: Help Prevent Errors in Your Care Yes Yes Strong Speak-Up!

396. AHRQ Pharmacy Health Literacy Center | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/health-literacy/improve/pharmacy/index.html
     January 01, 2024 - Medication errors are likely higher with patients with limited health literacy, as they are more likely … Medication errors are likely higher with patients with limited health literacy.

397. Labor and Delivery Unit Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety-fac-guide.html
     July 01, 2023 - 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. … or posting one on a rapid response cart or kit or on a wall is unlikely to be effective at reducing errors … Checklist effectiveness for reducing errors can be enhanced when— They are created or adapted to meet

398. Conclusions and Next Steps | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-6.html
     September 01, 2020 - Can we develop checklists for diagnostic error reduction that focus on errors of execution rather than … errors of planning?

399. Making Healthcare Safer III Patient Safety Practices | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/making-healthcare-safer/mhs3/practices.html
     April 01, 2020 - List of Patient Safety Practices Diagnostic Errors ( PDF , 2.3 MB) Clinical Decision Support Result … Opioids ( PDF , 1.8 MB) Opioid Stewardship Medication-Assisted Treatment Patient Identification Errors

400. Introduction | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety1.html
     September 01, 2022 - To Improve Diagnosis and Suggested Questions for Debriefing Case Studies Diagnostic errors … problem solving, to recognize and encourage nurses as important contributors to reducing diagnostic errors