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401. Conclusion | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-5.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

402. Learn About CUSP, Facilitator Notes | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/cusp/modules/learn/fac-cusp.html
     December 01, 2012 - Examples of Defects or Errors That Affect Patient Safety Slide 25. … Review the effects of errors and patient harm and the underlying causes of errors. … of checklists and guided communication tools were effective in reducing lapses in team functioning, errors … Examples of Defects or Errors That Affect Patient Safety Say: When identifying defects that affect … Examples of defects or errors that affect patient safety, and the interventions to alleviate them include

403. Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/studies/index.html?page=475
     January 01, 2024 - Low-Income (171) Maternal Care (182) Medicaid (359) Medical Devices (71) Medical Errors … Physicians are being called on to deliver patient-centered care, reduce medical errors, and generally … Newman-Toker proposed a novel framework for considering diagnostic errors, offering a unified conceptual … A unified conceptual model for diagnostic errors: underdiagnosis, overdiagnosis, and misdiagnosis. … Keywords: Diagnostic Safety and Quality, Medical Errors, Patient Safety Barnett ML , Linder

404. TeamSTEPPS Teamwork Attitudes Questionnaire (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-t-taq-questionnaire.pdf
     May 31, 2023 - Teams that do not communicate effectively significantly increase their risk of committing errors. … Poor communication is the most common cause of reported errors. 27.

405. 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.

406. 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

407. Chapter-8 - Diabetes (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/diabetes-1.pdf
     March 01, 2020 - The research on standardized protocols to reduce insulin administration errors that result in hypoglycemia … the past decade, the United Kingdom—more than any other Nation—has documented diabetes medication errors … through the National Diabetes Audit and instituted quality improvement projects to reduce errors and … Medication errors common for hospital diabetes. … In the computer group, no statistically significant effects of insulin dosing errors on hypo or

408. What Exactly Is Patient Safety? (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-Emanuel-Berwick_110.pdf
     July 02, 2008 - The traditional approach assumed that well-trained, conscientious practitioners do not make errors. … or equipment—result from “latent” errors, as demonstrated by James Reason.3 Latent errors are upstream … The notion that sharing information about medical errors was essential for effective patient safety … Additionally, increased media exposure of preventable medical errors raised troubling questions that … Patients’ and physicians’ attitudes regarding the disclosure of medical errors.

409. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership-cx.pdf
     June 03, 2021 - This care includes addressing both established and emerging safety concerns, such as diagnostic errors … Errors involve common conditions and nearly half of them have potential for patient harm. … The nature and magnitude of diagnostic errors and their tangible associated costs are drawing the attention … with effort, effective strategies, and input from others.7 Confronting the challenge of diagnostic errors … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.

410. Leadership To Improve Diagnosis: A Call to Action - Issue Brief 5 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dx-leadership.pdf
     June 03, 2021 - This care includes addressing both established and emerging safety concerns, such as diagnostic errors … Errors involve common conditions and nearly half of them have potential for patient harm. … The nature and magnitude of diagnostic errors and their tangible associated costs are drawing the attention … with effort, effective strategies, and input from others.7 Confronting the challenge of diagnostic errors … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.

411. Module 5 Evidence Base (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module5/ts2-0ltc_module5_sitmon_evbase.pdf
     January 01, 2013 - In fact, poor situation monitoring has been considered a contributor to clinical errors,9 whereas high … This can serve to reduce errors and thus enhance patient safety. … The potential for improved teamwork to reduce medical errors in the emergency department.

412. Prologue—Volume 1—Five Years Later—Are We Any Safer? (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/James.pdf
     January 01, 2004 - Views of practicing physicians and the public on medical errors. NEJM 2002;347(24):1,933– 40. 5. … Errors today and errors tomorrow. NEJM 2003;348(25):2,570–2.

413. TeamSTEPPS 2.0 Evidence Base: Situation Monitoring (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/ebsitmonitor.pdf
     January 01, 2013 - In fact, poor situation monitoring has been considered a contributor to clinical errors,9 whereas high … This can serve to reduce errors and thus enhance patient safety. … The potential for improved teamwork to reduce medical errors in the emergency department.

414. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dagnostic-safety-workgroupmeeting-notes-july2022.pdf
     November 03, 2022 - • Diagnostic Errors Focus o Initiated improvement project to better identify and facilitate the … reporting of diagnostic errors through voluntary event reporting (I- STAR).

415. An Overview of the CANDOR Process
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
     September 10, 2015 - 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.  

416. St. Jude Relies on AHRQ's Hospital Survey on Patient Safety Culture | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/cquips1402.html
     January 01, 2014 - For example, survey results in 2009 about feedback and communication of errors prompted St. … Just culture balances nonpunitive response to errors with elements of fair and just accountability. … communication openness, hospital management support for patient safety, and feedback and communication about errors

417. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/hotline/refs.html
     May 01, 2016 - Views on their role in preventing medical errors. Med Care Res Rev 2005 Oct; 62(5):601–16. 19. … Views of practicing physicians and the public on medical errors. … Errors, near misses, and adverse events in the emergency department: what can patients tell us? … Consumers can prevent medication errors (Web site).

418. Chapter 1. Building the Project Foundation: Gaining Leadership Support Within the Organization | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/chapter-1.html
     July 01, 2022 - ranged from 30 percent to 70 percent in two literature reviews. , A study of medication reconciliation errors … and risk factors at hospital admission noted that 36 percent of patients had errors in their admission … Medication History Collection and Reconciliation on Admission Average # of discrepancies/medication errors … per patient 2.2 Number of inpatient admissions per year 43,312 (2006) Potential medication errors … were potentially harmful to patient during hospitalization * 2.5% Number of harmful medication errors

419. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/measuredesc-dailyearlymobility-facguide.docx
     January 01, 2017 - provider’s hand every time the patient hears the letter A, and the provider will count the number of errors … To determine the number of errors, count the number of times the patient does not squeeze when the letter … Slide 21 Attention Screening Exam SAY: In the ASE column, record the number of errors counted during … the assessment, again remembering that more than two errors indicates inattention. … performed, if you do not know whether it was performed at all, or if you do not know the number of errors

420. Module 1 Slides
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module1/ts2-0ltc_module1_slides_intro.pptx
     January 20, 2006 - #› Introduction 3 Objectives Describe the TeamSTEPPS Master Trainer course Describe the impact of errors … How can we prevent errors?