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41. TeamSTEPPS Fundamentals Course: Module 1. Introduction | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/teamstepps/instructor/fundamentals/module1/igintro.html
    June 01, 2019 - Describe the impact of errors and why they occur. Describe the TeamSTEPPS framework. … How can we prevent medical errors? … Return to Contents Barriers to Team Performance Say: Errors can occur for many reasons, and … Many obstacles also can impair an individual or team's ability to work effectively and prevent errors … It was determined that 43 percent of errors resulted from problems with team coordination.

42. Meeting Minutes, November 2015 | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/news/events/nac/2015-11-nac/nacmtg1115-minutes.html
    May 01, 2016 - 2015, Summary Report Director's Update Health Information Technology Real World Use of MEPS Diagnostic Errors … Return to Contents Diagnostic Errors Elizabeth A. … the results of a large study, conducted by the Institute of Medicine (IOM), on reducing diagnostic errors … AHRQ and others should encourage and facilitate the voluntary reporting of diagnostic errors and near … is focusing on three goals from the IOM report—goal 6 concerning improving learning from diagnostic errors

43. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
    teamstepps.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.

44. Quality and Patient Safety Resources | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/resources/index.html
    December 01, 2022 - Quality and Patient Safety Resources Tips for preventing medical errors … Patient Safety Measure Tools & Resources Information about AHRQ efforts to reduce medical errors and

45. Diagnostic Safety Resource List (pdf file)
    teamstepps.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.

46. Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/research/publications/search.html
    January 01, 2024 - Diagnostic Safety Issue Brief #15 One of the best ways to collect information about diagnostic errors … 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

47. Tool: Check-Back (or Repeat-Back) | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
    July 01, 2023 - Some misunderstandings lead to serious medical errors, including misdiagnoses. … The message may also be misunderstood because of typing errors or autocorrected spellings that change … What communication errors were avoided?

48. Resource List - AHRQ Hospital Survey (pdf file)
    teamstepps.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.

49. TeamSTEPPS, Module 8: Change Management (Instructor Guide) (pdf file)
    teamstepps.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.

50. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
    teamstepps.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.

51. Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/reports/engage/medlist.html
    October 01, 2022 - strategy helps to improve documentation because we can see the medications and decrease medication errors … In the primary care setting, medication safety issues include prescribing errors, contraindications, … That’s at least 160 million medication errors annually .

52. AHRQ's Quality & Patient Safety Programs by Setting: Ambulatory Care | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/patient-safety/settings/ambulatory/index.html
    July 01, 2022 - Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit  aims to assist primary care practice teams … with a systematic approach to reduce diagnostic errors among children in three important areas: Elevated … Ambulatory Settings is designed to help staff actively engage patients and their care partners to prevent errors

53. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
    September 01, 2022 - Cross-Cutting: Health Information Technology Cross-Cutting: Other Topics Delirium Diagnostic Errors … Infection Control: Urinary Tract Infection Patient and Family Engagement Patient Identification Errors … Patients Summary of Evidence (Not reviewed) (Not reviewed) Fatigue, Sleepiness, and Medical Errors …   MHS I (2001) MHS II (2013) MHS III (2020) Patient Safety Practices Targeted at Diagnostic Errors … Radiological Patient Safety Practices  MHS I (2001) MHS II (2013) MHS III (2020) Reducing Errors

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

55. Final Progress Report: Leveraging a Social Network of Elders and Families To Improve Medication Safety at Transitions of Care (pdf file)
    teamstepps.ahrq.gov/sites/default/files/2024-01/quintana-report.pdf
    January 01, 2024 - Figure 14 demonstrates the aggregated occurrences of navigation errors in scenarios 1-3. … Adverse drug events and medication errors in Australia. … Medication errors in elderly people: contributing factors and future perspectives. … Awareness of technology-induced errors and processes for identifying and preventing such errors. … Technology-induced errors.

56. Fact Sheets | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/research/findings/factsheets/index.html
    February 01, 2024 - Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets Medical Errors … Performance Initiative Comparative Health System Performance Initiative Fact Sheet (PDF, 162 KB) Medical Errors

57. New Challenge Competition Offers Prizes for Ideas on Advancing AHRQ’s CDS Connect | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/news/newsletters/e-newsletter/881.html
    September 01, 2023 - Issue Brief Describes Strategies for Improving Clinician Psychological Safety in Reporting Diagnostic Errors … Issue Brief Describes Strategies for Improving Clinician Psychological Safety in Reporting Diagnostic Errors … describes strategies for improving clinician psychological safety in reporting and discussing diagnostic errors … The brief highlights specific barriers and challenges to reporting and learning from diagnostic errors

58. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
    teamstepps.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
    May 01, 2023 - 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, … Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions … such as the use of tall man lettering in order to prevent such errors. 6. … Patient Safety Primer: Medication Errors and Adverse Drug Events 9.

59. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    teamstepps.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

60. Well-Child Visits on the Rise, But Disturbing Gaps Remain for Underserved Populations | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/news/newsletters/e-newsletter/828.html
    August 01, 2022 - AHRQ Views Blog: AHRQ Expands Its Repertoire To Eliminate Diagnostic Errors . … AHRQ Views Blog: AHRQ Expands Its Repertoire To Eliminate Diagnostic Errors In a new blog post, AHRQ … An estimated 250,000 diagnostic errors occur annually in U.S. hospitals. … Defining and studying errors in surgical care: a systematic review .