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301. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
     January 01, 2018 - to Improve Safety Tejal Gandhi Handwriting 16 Ways IT Can Improve Safety • Prevent errors … and providing feedback about adverse events Bates, Gawande 2003 Main Strategies for Preventing Errors … decision support Bates, Gawande 2003 Optimize the Use of HIT • We know that some technologies reduce errors … • Overdependence on technology • Shift in power • Never-ending technology demands • Emotions • New errors … Use of HIT to Improve Safety Handwriting Ways IT Can Improve Safety Main Strategies for Preventing Errors

302. Brain Based Learning
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps_webinar_012017.pptx
     January 01, 2017 - Rather than avoid errors, learners are asked to embrace errors as part of the initial events of learning … Medical Teacher, 2011, 33:1, 34-38 Obvious Errors (Others) Subtle Errors (Others) Obvious Errors (Self … when errors are not detected, Learners get more information on how to detect them. … all errors need to be represented—slips, errors, mistakes Dror I. … to perform subtle errors and the other team grade them (they circle the errors they will perform ahead

303. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/lepguide/lepguide.pdf
     September 01, 2012 - Patient Safety Terminology Medical errors*: Medical errors happen when something that was planned as … Most errors result from problems created by today’s complex health care system, but errors also happen … If anything, errors related to LEP are bundled as being caused by “communication errors,” which does … We identified three common causes of errors (or potential errors) for LEP and culturally diverse patients … Address Root Causes To Prevent Medical Errors Among LEP Patients Background Medical errors among LEP

304. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
     September 01, 2012 - Patient Safety Terminology Medical errors*: Medical errors happen when something that was planned as … Most errors result from problems created by today’s complex health care system, but errors also happen … If anything, errors related to LEP are bundled as being caused by “communication errors,” which does … We identified three common causes of errors (or potential errors) for LEP and culturally diverse patients … Address Root Causes To Prevent Medical Errors Among LEP Patients Background Medical errors among LEP

305. Guide Promotional Postcard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
     April 01, 2018 - Annually, 1 in 20 outpatients experiences a diagnostic error 55% of patients said diagnostic errors … 9 ED admissions are related to an adverse drug event An estimated 160 million medication errors … Reduce errors and improve efficiency by setting the visit agenda together with Be Prepared To Be

306. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
     January 01, 2024 - and the quality of information about oral chemotherapy errors from various sources. … We proposed to collect data about oral chemotherapy-related medication errors by using literature and … and the quality of information about oral chemotherapy errors from various sources) 5.1.1 Incident … Underreporting is common, because clinicians may be reluctant to report their own errors. … Medication errors involving oral chemotherapy. Unpublished manuscript.

307. Medication Error Reporting Systems: Challenges, Lessons, Future Direction (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cousins-report.pdf
     January 01, 2024 - Key Words: medication errors, reporting systems, patient safety, MEDMARX® Section 2. … and patterns of errors that identify systemic vulnerabilities affecting healthcare organizations. … The IOM targeted medication errors as an important focus for prevention efforts. … As one important strategy for reducing medical errors, the IOM called for mandatory error reporting … Voluntary reporting of medication errors. Am J Health-Syst Pharm. 2002; 59(23):2326-2328. 6.

308. Additional TeamSTEPPS Videos: Check-Back in Inpatient Surgical Teams | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/resources/additional/check-back-team.html
     July 01, 2023 - instructions are described—and heard—correctly is an important safeguard against potential medication errors … part of an evidence-based approach to safer care, can improve communication and reduce the risk of errors

309. Final Progress Report: Proactive Risk Reduction in Medication Prescribing in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
     January 01, 2024 - risk assessment to characterize systemic and behavioral elements that increase the risk of serious errors … Scope: There are currently no demonstrably effective solutions to the problem of errors in prescribing … Our previous study identified seven major proximal errors in the medication handling process that cause … for interventions and assess the extent to which these interventions could lower the rate of these errors … Because the errors associated with ADEs in this setting usually occur 3 during prescribing and

310. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Schiff (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new_sops_diagnostic_safety-schiff.pdf
     January 01, 2020 - • Frequent • Important • Overlooked • Matter • Not easy to measure 17 Frequent - #1 Type of Errors … Diagnostic errors 2. Opioid safety across the continuum of care 3. … • Spotty follow-up • Most diagnoses resolve,…or evolve w/errors unnoticed • Elusive to capture with … Research and Quality's activities in patient safety research IOM Report September 2015 Diagnosis Errors … Frequent -#1 Type of Errors Most Common Types of Medical Error Experienced by MA Residents 21% Experienced

311. Module 9. Preparing and Presenting Performance Data | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/tools/pf-handbook/mod9.html
     March 01, 2022 - These mistakes can be difficult to identify but can introduce significant errors into any patient and … expected, or seem “strange” to clinicians and staff, this should be a red flag to check for mapping errors … Errors mapping data entered into an EHR to the database variables are frequent. … When this happens, it is important that you listen carefully to their discussion of the errors that they … Once you have helped the practice correct these errors and can present the corrected data again, you

312. Brain Based Learning Strategies to Improve TeamSTEPPS® Deployment and Health Care High Reliability | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/events/webinars/jan-2017.html
     January 01, 2017 - Fear of Making Mistakes/Errors Slide 39. Frame Errors Positively Slide 40. … Rather than avoid errors, learners are asked to embrace errors as part of the initial events of learning … (others), Subtle errors (others), Obvious errors (self), subtle errors (self), and error recovery. … All errors need to be represented—slips, errors, mistakes. Dror I. … teams to perform subtle errors and the other team grade them (they circle the errors they will perform

313. Producing Accurate Clinical Quality Reports for Population Health: A Delivery System-Oriented Approach to Report Validation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/ehr-reports.pdf
     March 01, 2016 - They found no errors in the report logic. … For validation purposes it is useful to categorize clinical quality report errors into “inclusion errors … Other inclusion errors can be caused by workflow issues, which are errors caused by failure to note … Exclusion Errors The fact that with exclusion errors the patient is not in the report means that the … All reports contain errors, and 2.

314. Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
     April 01, 2025 - ascribed to error or substandard care, called preventable adverse events, was created to capture errors … As the field evolved to consider diagnostic errors as a subset of medical error, the term diagnostic … adverse event 16 was introduced and defined as diagnostic errors that cause harm. … Safety-I often defines factors that contribute to adverse events as failures or errors, even if it uses … One consequence of defining failure or problems as “errors” is a strong tendency by those unfamiliar

315. About the Toolkit Development | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
     July 01, 2023 - addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication errors … High-reliability systems and a culture of learning from errors (or near misses) are needed to minimize

316. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/21093-Lambert-draft-1.pdf
     November 20, 2017 - Predicting and Detecting Drug Name Confusion Errors 3.A. … Automated detection of look-alike/sound-alike medication errors. … Both studies nonetheless found scores of potential errors. … Does Tall Man lettering prevent drug name confusion errors? … How many hospital pharmacy medication dispensing errors go undetected?

317. Speaking Plainly: Communicating the Patient’s Role in Health Care Safety (pdf file)
     www.ahrq.gov/downloads/pub/advances/vol4/Miranda.pdf
     July 01, 2004 - Others specified particular actions that patients could take to avoid errors, such as maintaining a … refers to “medical errors.” … Agency for Healthcare Research and Quality: 20 tips to help prevent medical errors. … Preventing medical errors: communicating a role for Medicare beneficiaries. … Prescription errors tied to lack of advice: pharmacists skirting law, Mass. study finds.

318. Speaking Plainly: Communicating the Patient’s Role in Health Care Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Miranda.pdf
     July 01, 2004 - Others specified particular actions that patients could take to avoid errors, such as maintaining a … refers to “medical errors.” … Agency for Healthcare Research and Quality: 20 tips to help prevent medical errors. … Preventing medical errors: communicating a role for Medicare beneficiaries. … Prescription errors tied to lack of advice: pharmacists skirting law, Mass. study finds.

319. The Impact of a Patient Safety Program on Medical Error Reporting (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Woolever.pdf
     January 01, 2001 - Medical facilities have long had systems in place to monitor errors. … Formal teamwork training improved teamwork and reduced emergency department errors. … A look into the nature and causes of human errors in the intensive care unit. … Medical Team Management: using teamwork to prevent medical errors. … Treat systems, not errors, experts say. JAMA 1996;276:1537–8. 23.

320. Advancing Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advancing-patient-safety.html
     March 01, 2024 - safety findings, investigative approaches, process analyses, and practical tools for preventing medical errors … This compendium describes what federally funded programs have accomplished in understanding medical errors