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461. Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Davis.pdf
     February 12, 2004 - Defense (DoD), per the direction of President Clinton, developed an action plan to reduce medical errors … The system has helped to identify patterns of patient safety errors and areas where patient safety events … analyze the data; [and] develop and execute action plans for addressing patterns of patient care errors … It also is inspected for any gross data input errors or format alterations. … Doing what counts for patient safety: Federal actions to reduce medical errors and their impact.

462. Preparing Data from CAHPS Surveys for Analysis (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/preparing-data-for-analysis.pdf
     May 15, 2017 - Their results should then be compared to identify and correct data entry errors. … Finally, if you have programmed the CAHPS instrument into a Web survey, issues with skip pattern errors … • Having an original file will allow you to correct any data errors made during the cleaning process … An audit will also identify possibly coding errors. … Conducting the audit immediately after data entry allows you to catch errors before proceeding with

463. Developing a Community-Wide Electronic Shared Medication List (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-Stock_113.pdf
     June 15, 2005 - Introduction Thousands of deaths and injuries occur annually in hospitals due to preventable medical errors … , and preventable drug reactions are a leading cause of these errors.1 An Institute of Medicine (IOM … ) report2 suggests that medication errors leading to adverse drug events (ADEs) are as frequent or more … Does a shared electronic medication list reduce medical errors and adverse drug events? … Preventing medication errors.

464. Environmental Scan of Patient Safety Education and Training Programs (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
     June 01, 2013 - and maximize the likelihood of intercepting errors when they occur. … These events include "errors," "deviations," and "accidents.” … Patient safety efforts aim to reduce errors of commission or omission. … /Preventable Adverse Drug Events 96 420 ---- Administration Errors 14 419 ---- Dispensing Errors … 11 448 ---- Monitoring Errors and Failures 23 417 ---- Ordering/Prescribing Errors 6 418 --

465. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part II: Appendixes (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
     September 01, 2019 - (C1) We are informed about errors that happen in this unit. … (C2) In this unit, we discuss ways to prevent errors from happening again. … (A17R) Our procedures and systems are good at preventing errors from happening. … (C1) We are informed about errors that happen in this unit. … (C2) In this unit, we discuss ways to prevent errors from happening again.

466. Survey on Patient Safety (facility version) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     November 18, 2019 - Our procedures and systems are good at preventing errors from happening ........................... … We are informed about errors that happen in this unit .............................. 1 2 3 4 5 … In this unit, we discuss ways to prevent errors from happening again ...... 1 2 3 4 5 6.

467. Survey on Patient Safety (facility version) (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
     November 15, 2019 - Our procedures and systems are good at preventing errors from happening (1 (2 (3 (4 (5 SECTION … We are informed about errors that happen in this unit (1 (2 (3 (4 (5 4. … In this unit, we discuss ways to prevent errors from happening again (1 (2 (3 (4 (5 6.

468. Medical Team Training Programs in Health Care (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Baker.pdf
     February 01, 2005 - perform it, it is likely that teamwork plays an important role in ensuring patient safety and avoiding errors … In health care, shared goals might include maintaining a patient’s health status and avoiding errors … our case study investigation.5 MedTeamsTM The primary purpose of MedTeams is to reduce medical errors … Reducing errors in emergency medicine through team performance: the MedTeams project. … In: enhancing patient safety and reducing errors in health care.

469. Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions (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-Woods_78.pdf
     July 23, 2008 - solutions; (6) orders and consultations; (7) organizational responsibility and communication about errors … and solutions 3 Organizational responsibility for safety Learning from errors Thank people … Risk assessment and learning from errors. 8. Education and information. 9. … Errors in a busy emergency department. Ann Emerg Med 2003; 42: 324- 333. 10. … The potential for errors in children with special health care needs. 11.

470. Implement Teamwork and Communication for Perinatal Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
     May 01, 2017 - • Identify barriers to communication, • Describe the connection between communication and medical errors … According to the Joint Commission, these errors are reported over 50 percent of the time and represent … • Were errors made or avoided? And • Are resources available? … for the patient and asserting a corrective action, the team member has an opportunity to correct errors … • Research supports the connection between communication errors and errors in patient care delivery

471. Executive Briefing
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/leadership-brief/ts-leadershipbrief.pptx
     January 01, 2013 - Page ‹#› In 1999, the Institute of Medicine (IOM) estimated the annual cost of preventable medical errors … Cost of one lawsuit vs. implementation of TeamSTEPPS; recent data on the cost or number of medical errors … The cost required to implement TeamSTEPPS is minimal compared with the cost of medical errors. … The IOM concluded that medical errors could be significantly reduced through fundamental changes in our … Lessons from the cockpit: how team training can reduce errors on L&D.

472. Patient and Family Engagement in the Surgical Environment Module | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/pf-engagement-slides.html
     May 01, 2017 - members— 5 Generally assume that most care is safe and that there are system checks to prevent medical errors … Blame provider, not system, for medical errors. Underestimate medical errors. … Patient and family engagement in health care may decrease medical errors by allowing patients and family … Help prevent specific safety events and/or medical errors.

473. Financial and Demographic Influences on Medicare Patient Safety Events (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
     January 01, 2004 - In fact, the IOM Committee recommended nothing less than a 50 percent reduction in medical errors over … documented recently in two additional studies.4, 5 Such recommended reductions in patient safety errors … and the errors are corrected for clustering at the hospital-year. … Robust standard errors corrected for clustering at the hospital are in parenthesis. … Also, due to data limitations, our patient safety measures do not include medication errors.

474. Resource List - AHRQ Ambulatory Surgery Center Survey (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-resource-list.pdf
     April 01, 2023 - It highlights bright spots: organizations that use a just culture approach to investigating errors, … The brochure reinforces the nonpunitive reporting policy and encourages all coworkers to report errors … Patient Safety Primer: Medication Errors https://psnet.ahrq.gov/primers/primer/23 A growing evidence … It makes the case that true transparency will result in improved outcomes, fewer medical errors, more … Patient Safety Primer: Medication Errors 14.

475. Situation Monitoring: Severe Hypertension - PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring.pptx
     July 01, 2023 - Errors Are we making errors? How do we self-correct? … Errors – Are we making any errors? How do we self-correct? … Errors Were errors made? Avoided? Can they be prevented? … • Errors o Are we making errors? How do we self-correct? … •Errors oAre we making errors? Howdowe self-correct?

476. Serious Reportable Adverse Events in Health Care (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
     December 01, 2000 - Stegun Abstract Health care errors resulting in patient harm are a leading cause of morbidity and … In 1999, the Institute of Medicine (IOM) recommended that health care errors and adverse events be reported … Patient death or serious disability associated with a medication error (e.g., errors involving the … This should be an important initial step to addressing these types of health care errors. … Doing what counts for patient safety: Federal actions to reduce medical errors and their impact.

477. PowerPoint Presentation
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module8/ts2-0ltc_module8_slides_chmgmt.pptx
     January 31, 2006 - Page ‹#› Change Management Change Management Objectives List the Eight Steps of Change Identify errors … forces, and pressures for the next change TEAMSTEPPS 05.2 Mod 8 LTC 2.0 Page ‹#› Change Management Errors

478. AHRQ Safety Program for Perinatal Care: Shadowing Another Professional Tool (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/professional-tool.docx
     May 01, 2017 - Discuss with the clinician you shadowed what you believe may reduce communication errors and teamwork … Did you observe any errors in transcription of orders by the clinician you shadowed? 4.

479. newbref
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module8/slchangemgmt.pptx
     January 31, 2006 - Mod 8 2.0 Page ‹#› Change Management Page ‹#› Objectives List the Eight Steps of Change Identify errors … pressures for the next change TEAMSTEPPS 05.2 Mod 8 2.0 Page ‹#› Change Management Page ‹#› Errors

480. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
     April 01, 2018 - Medical errors in U.S. pediatric inpatients with chronic conditions. … Relationship between medication errors and adverse drug events. … Views of practicing physicians and the public on medical errors. … Medical errors—what and when: What do patients want to know? … Medication errors and adverse drug events in pediatric inpatients.