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81. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
    July 14, 2023 - • EPC Program o Released the final report Diagnostic Errors in the Emergency Department: A Systematic … CDC • Division of Laboratory Systems o Health Equity and Diagnostic Errors: DLS envisioned and is … /grants/guide/rfa-files/RFA-HS-23-011.html https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency … /research https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency/research https:// … • Preventable Harm From Pediatric Outpatient Medication Errors: Measure Development o Project

82. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
    January 01, 2019 - By the end of the workshop, participants should: • Be introduced to an understanding of why errors … 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, … Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans To Enhance Safety … The best practices are designed to help alert hospitals and focus their efforts on errors that cause

83. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
    pbrn.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.

84. Fallpxtool3O (doc file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3o.docx
    January 01, 2008 - Total Errors: _______ SCORING*: 0-2 errors: normal mental functioning 3-4 errors: mild cognitive impairment … 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment * One more

85. Hospital Survey on Patient Safety Culture Version 2.0: Composites and Items (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
    August 01, 2019 - When staff make errors, this unit focuses on learning rather than blaming individuals. A13. … 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. C2. … When errors happen in this unit, we discuss ways to prevent them from happening again. C3.

86. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
    August 01, 2022 - Slide 7 Say: It is important to understand the distinction between events and errors when an … Errors are defined as an act of commission (doing something wrong) or omission (failing to do the right … The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … and errors that are not adverse events.

87. FileNewTemplate
    pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module1.pptx
    March 01, 2010 - website. 2 Module Objectives After completing this module, you will be able to: Describe the impact of errors … Module 1: Introduction ‹#› After completing this module, you’ll be able to: Describe the impact of errors … occur and how to correct for these errors. … Lessons from the cockpit: How team training can reduce errors on L&D (Grand Rounds) Contemporary OB/Gyn … Module 1 Summary In this module you learned to: Describe the impact of errors and why they occur Describe

88. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    pbrn.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

89. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
    August 01, 2022 - Thus, it is no wonder that diagnostic errors occur. … Diagnostic Errors in the Emergency Department: A Sys- tematic Review. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Changes in medi- cal errors after implementation of a handoff program. … The importance of cognitive errors in diagnosis and strategies to minimize them.

90. TeamSTEPPS 2.0 Module 8: Change Management
    pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule8.pptx
    March 28, 2006 - After completing this module, you'll be able to list the eight steps of change, identify errors common … Practices Step 3: Prioritize Best Practices Step 4: Review Kotter’s 8 Steps of Change Step 5: Common Errors … And then step five, common errors. … Discuss what some of the common errors are when trying to make an organizational change. … listed on the following slide. 18 Errors Common to Organizational Change (Slide 12) Common errors:

91. Long-term Care Resources | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
    November 01, 2021 - Toolkits, recommendations, and other resources for long-term care facilities to improve quality, reduce errors

92. Reinforcing the Value and Roles of Nurses in Diagnostic Safety - Issue Brief (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/nurse-role-dxsafety.pdf
    September 02, 2022 - AHRQ Publication No. 22-0026-4-EF. 1 e Introduction Diagnostic errors are common and costly, … Nurses are key in preventing deadly diagnostic errors in cardiovascular diseases. … Diagnosis is a team sport - partnering with allied health professionals to reduce diagnostic errors. … Diagnostic error: safe and effective communication to prevent diagnostic errors. … Communication breakdowns and diagnostic errors: a radiology perspective.

93. Patient Safety and Quality Improvement | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/index.html
    January 01, 2024 - Diagnostic Safety and Quality Funding research to better understand how diagnostic errors … Continuing Education Resources Tips for preventing medical errors and promoting

94. Diagnostic Safety Resource List (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
    May 01, 2023 - It thus potentially prevents diagnostic errors by preventing patients from “falling through the cracks … Each guide provides foundational education about diagnostic errors and tangible ideas and suggestions … It highlights bright spots: organizations that use a Just Culture approach to investigating errors, … Harnessing Improvement to Reduce Diagnostic Errors and Delays (Podcast) http://www.ihi.org/resources … Harnessing Improvement to Reduce Diagnostic Errors and Delays (Podcast) 4.

95. Explicit and Standardized Prescription Medicine Instructions | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/health-literacy/improve/pharmacy/instructions.html
    September 01, 2020 - Instructions Explicit, standardized instructions improve patients’ understanding, and possibly reduce errors … To improve patients' understanding, and possibly reduce errors while improving adherence, AHRQ grantee … Studies have shown that errors are more likely with more complex regimens.

96. Resource List - AHRQ Hospital Survey (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
    April 01, 2023 - Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans To Enhance Safety … It makes the case that true transparency will result in improved outcomes, fewer medical errors, more … This article lists 10 tools to assist in better patient handoff communications and to avoid errors. … The best practices are designed to help alert hospitals and focus their efforts on errors that cause … Patient Safety Primer: Medication Errors and Adverse Drug Events 23.

97. TeamSTEPPS 2.0 Module 1: Introduction
    pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps/instructor/onlinecourse/tsonlinemodule1.pptx
    January 01, 2011 - How can we prevent medical errors? Can something similar happen in our organization? … Think about some ways we prevent medical errors. … How can we prevent medical errors? Can something similar happen in our organization? … or preventing errors. … There's a lot of information here on the history of medical errors and patient safety.

98. Health Care Facility Design Safety Risk Assessment Toolkit | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html
    October 01, 2020 - facilities can minimize such safety problems as health care-associated infections, patient falls, medication errors … The toolkit: Targets six areas of safety—infections, falls, medication errors, security, injuries of

99. TeamSTEPPS, Module 8: Change Management (Instructor Guide) (pdf file)
    pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module8/igchangemgmt.pdf
    February 25, 2014 - CHANGE MANAGEMENT: HOW TO ACHIEVE A CULTURE OF SAFETY SUBSECTIONS • Eight Steps of Change • Errors … Errors Common to Organizational Change 17 2 mins 5. … COMMON ERRORS TO CHANGE (5 Minutes) 1. … Compare the errors to those found presented on the slide that accompanies page 17. … Kotter identifies ways to institutionalize change and counter these errors.

100. Meeting Minutes, April 2019 | Agency for Healthcare Research and Quality
     pbrn.ahrq.gov/news/events/nac/2019-04-nac/nacmtg0419-minutes.html
     July 01, 2019 - Brady described AHRQ’s current efforts to improve diagnosis, that is, to reduce diagnostic errors in … More than 4 million U.S. citizens each year suffer severe consequences as a result of diagnostic errors … Brady stated that the Agency’s goal is to reduce the rate of diagnostic errors occurring each year in … A reduction of 1 million diagnostic errors in 1 year would potentially result in a savings of $500 million … It has identified a pool of individuals who have experienced diagnostic errors.