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1881. Improving Patient Safety in Community Pharmacies: A Resource List for Users of the AHRQ Community Pharmacy Survey on Patient Safety Culture (pdf file)
      www.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.

1882. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
      www.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 … 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

1883. Using the AHRQ Pharmacy Survey on Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/pharmwebinar/cousins_introslides.pdf
      October 29, 2013 - Safety in Community Pharmacies More than 61,000 Community Pharmacies (2011) One estimate found 4 errors … Medication Dispensing Errors in Community Pharmacies: A Nationwide Study 8 8 Technical Expert

1884. Meeting Minutes, April 2019 | Agency for Healthcare Research and Quality
      www.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.

1885. | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/programs/index.html?page=2
      Research AHRQ offers toolkits, recommendations, and other resources to improve quality, reduce errors … toolkits, recommendations, and other resources for long-term care facilities to improve quality, reduce errors

1886. Yale Center for Healthcare Innovation, Redesign, and Learning | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/resources/learning-lab/yale-center-long-desc.html
      June 01, 2020 - These include identification errors, delayed or missed diagnoses, redundant testing, treatment delays … or errors, medication errors, and unexpected clinical deterioration.

1887. AHRQ-Funded Patient Safety Project Highlights (pdf file)
      www.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.

1888. Improving Your Laboratory Testing Process Toolkit (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
      December 01, 2017 - Errors in managing tests are more common than most of us realize. … Addressing the system can reduce errors. Figure 1. … Medical testing errors in this office do not harm patients. 9. … Providers and staff openly discuss causes and effects of errors. 10. … Reduce errors in delayed notification of lab results.

1889. Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Devine_83.pdf
      April 06, 2008 - quality of care; computerized provider order entry (CPOE) systems are believed to reduce medication errors … systems and introduces unpredicted and unintended consequences, including the generation of new types of errors … , thus minimizing the occurrence of prescription-related medication errors. … Generation of new kinds of errors. 8. Changes in the power structure. 9. … Role of computerized physician order entry systems in facilitating medication errors.

1890. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
      April 22, 2004 - Alper Abstract Many articles in the medical literature state that medical errors are the result of … From this perspective, all medical errors and adverse events are somebody’s fault. … This fork was inspired by research that uncovered a disturbing numbers of errors in health care.10, … Medication errors observed in 36 health care facilities. … Medication errors and pediatric inpatients. JAMA 2001 Apr;285(16):2114–20. 27.

1891. Voluntary Hospital Coalitions to Promote Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rask.pdf
      January 01, 2004 - the planning stages well before the Institute of Medicine published its landmark report on medical errors … PHA provides both leadership and support for reducing errors pertinent information. … use (SMU) program The SMU program, which focuses on reducing the frequency of medication- related errors … , and develops an improvement plan for at least one of those errors. … PHA provides both leadership and support for reducing errors << /ASCII85EncodePages

1892. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
      May 01, 2011 - Scenarios for second-victims: Patient or family “connects” with staff member Pediatric cases Medical errors … Module 6 7 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 … AHRQ Primer: Support for Clinicians Involved in Errors and Adverse Events (Second Victims) Wachter RM

1893. Ldusafety Facguide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
      May 01, 2017 - presentation, we will do the following: Describe the rationale for the use of checklists for reducing errors … 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. … Checklist effectiveness for reducing errors can be enhanced when— they are created or adapted to meet

1894. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
      www.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.

1895. Hospital Survey on Patient Safety Culture: Background and Information for Translators (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
      September 01, 2009 - Our procedures and systems are good at preventing errors from happening. A10. … We are informed about errors that happen in this unit. C5. … In this unit, we discuss ways to prevent errors from happening again. 7. … Nonpunitive Response to Errors (More about this dimension: In a nonpunitive environment, when a mistake … Nonpunitive Response to Errors

1896. What Can Leaders Achieve by Prioritizing Diagnostic Safety? | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-4.html
      June 01, 2021 - from an inaccurate or delayed diagnosis, making it the number one cause of serious harm among medical errors … community health is an important strategy in combating preventable harm of all types, including diagnostic errors

1897. Engaging Patients and Families in Their Health Care | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/patients-families/patient-family-engagement/index.html
      April 01, 2018 - This toolkit is designed to help staff actively engage patients and their care partners to prevent errors … effectiveness reviews that cover health topics suggested by the public. 20 Tips to Help Prevent Medical Errors … Other Resources Question Builder 20 Tips To Help Prevent Medical Errors Patients and Providers

1898. The Science of Improving Patient Safety
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
      March 01, 2009 - 62,000 deaths from central line-associated blood stream infections per year8 4 4 How Can These Errors … participates in rounds A point-of-care pharmacist or one who participates in rounds reduces prescribing errors … A look into the nature and causes of human errors in the intensive care unit.

1899. St. Joseph’s Hospital Improves Patient Safety Using AHRQ Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/201511.html
      May 01, 2015 - very good, we frequently worked with incorrect information from the home medication list, and these errors … During a two-month study, the pharmacy corrected 2.3 errors per patient. St.

1900. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/engage/appc.html
      March 01, 2017 - strategies used by AHRQ to identify published literature in Patient Safety Net (PSNet): "medical errors … mistake*"[All Fields] OR "adverse event*"[All Fields] OR checklist ((medical error [mh] OR Diagnostic errors