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321. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/169-cusp-science-safety-slides.pptx
     October 01, 2024 - We are human and errors happen. Our system is not perfect, and it is increasingly complex. … Communication errors are common. … Healthcare is noisy and chaotic; communication errors are common. … Due to psychological safety, there is no risk when people report their errors and near-misses. … Science of Safety 17 Swiss Cheese Model: Layers of Defense10 Layers of defenses prevent or mitigate errors

322. Rationale for Improvement Tools | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-3.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Improvement Tools Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors … mitigating both cognitive factors such as bias and misdiagnosis/misinterpretation, as well as system errors … threats such as having the proper tubing for blood transfusion available in all rooms) and cognitive errors

323. Appendix, MATCH Resources for Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/appendix/app-12.html
     July 01, 2022 - Medication errors are the most common health care errors. … The Massachusetts Coalition for the Prevention of Medical Errors Massachusetts Coalition for the Prevention … of Medical Errors provides a formatted medication list that is a useful way to organize information

324. Appendix, MATCH Resources for Patients | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-12.html
     July 01, 2022 - Medication errors are the most common health care errors. … The Massachusetts Coalition for the Prevention of Medical Errors Massachusetts Coalition for the Prevention … of Medical Errors provides a formatted medication list that is a useful way to organize information

325. Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
     March 08, 2019 - a strategy and framework for healthcare organizations to measure, analyze, and reduce diagnostic errors … DOD • Deep-dive analysis of treatment delays that result in significant errors. … • Contributions of human factors to errors that have led to harm. … The Society to Improve Diagnosis in Medicine will hold its annual Diagnostic Errors in Medicine meeting

326. Final Progress Report: Risks of Inaccurate or Incomplete Preoperative Assessments in Freestanding ASCs (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/kupka-report.pdf
     January 01, 2024 - and speculate that outpatient settings may be more prone to errors than inpatient settings. … Still, few studies have documented the types of errors that may occur in the outpatient surgical setting … and kill several thousand each year in the United States. 32 Although errors are common throughout … Preventing Errors In The Outpatient Setting: A Tale Of Three States. … Failure Mode And Effect AnalysisTM: A Technique to Prevent Chemotherapy Errors.

327. Translating Patient Safety Research into Clinical Practice (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
     January 01, 2004 - Medication errors are the primary outcome. … are among the most common types of medical errors.2–8 In the Harvard Medical Practice Study, adverse … Of these adverse events, 25 to 75 percent were preventable.2, 13, 17 Errors can occur at several … errors change? … Relationship between medication errors and adverse drug events.

328. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
     January 01, 2024 - Some hazards increase the risk of errors, and errors themselves may be hazards for patient harm. … Hazards do not necessarily lead to errors or harm, but hazards increase the risk of them. … Some hazards increase the risk of errors, and errors themselves may be hazards for patient harm. … Preventing Medication Errors. Washington DC: National Academy Press; 2007. 18 4. … Patient safety efforts should focus on medical errors.

329. Final Progress Report: Patient Safety in Hospice Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
     January 01, 2024 - the process of home hospice care, only a few interviewees recalled any incidents or harm related to errors … country, estimated that between 44,000 and 98,000 people die each year in hospitals due to medical errors … Lack of reports of medical errors: Published patient safety research in office settings suggests that … these interviews would include many descriptions of medical errors or systems issues – contributing … errors, problems with clinical procedures, or hospice infrastructure issues.

330. Transforming Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/transform.html
     December 01, 2017 - a Safer Health System , exposed the tremendous costs, both in human and financial terms, of medical errors … The national cost to the economy of these errors is between $17 billion and $29 billion. … change their cultures and care processes to produce safer health care environments with fewer medical errors … Medication errors. … . 13 Patient rooms that can be adapted for the acuity of a patient can also reduce errors.

331. Understand the Science of Safety for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
     May 01, 2017 - • In 1999, 44,000 to 99,000 people die from medical errors in hospitals each year. … SAY: Errors occur within the health care setting because health care professionals are human, and … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine

332. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - Resilient staff have the ability to detect, contain, and mitigate defects and errors. 5. … • Reduce errors through prevention. … • Reduce costs associated with errors. … Medical errors: The scope of the problem. AHRQ Pub. 00-P037. … High-alert medications: Safeguarding against errors. In: Cohen MR, ed, Medication errors.

333. Safe Practices for Better Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
     April 01, 2004 - Not surprisingly, health care errors and consequent adverse events are a leading cause of death and … in the United States,1, 2 even though methods to prevent many of these errors exist. … Use of hand-held electronic prescribing devices to reduce medication errors. 5. … Use of CPOE compared to verbal orders to reduce transcription errors. 8. … Use of simulator-based training to reduce errors. 11.

334. Conclusions and Next Steps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-5.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Next Steps Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors

335. Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
     April 30, 2022 - Stepdown Units SOPS Survey -- 1,035 responses over 11 years Key takeaways: Positive: Response to errors … Safety Survey (Communication; 1 unit data only) Communication about error 82 +15 We are informed about errors … that happen in this unit. 80 +15 When errors happen in this unit, we discuss ways to prevent them … Level of explicit culture and teamwork Level of system reliability by design High High Human errors … interact in a predictable manner and can be effectively mitigated Low Low Human errors interact

336. Getting Ready for Measurement: Overcoming Barriers and Taking Next Steps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-3.html
     June 01, 2020 - Nevertheless, as the burden of diagnostic errors is increasingly recognized and as measurement strategies … to use the data already available to them to begin to detect, understand, and learn from diagnostic errors … While diagnostic errors occur across the spectrum of medical practice, measurement should be strategic … While diagnostic errors occur across the spectrum of medical practice, measurement should be strategic … implementation balance validity and yield (i.e., an estimate of the proportion of cases with diagnostic errors

337. Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Graham.pdf
     April 14, 2004 - CU conducted a 3-year project that collected medical errors from 38 primary care practices affiliated … Process Errors Detected in Family Physician Offices (Testing Process Errors). … The ASIPS PSRS accepted clinician and staff reports of errors anonymously or confidentially. … The Testing Process Errors study involved eight family practice offices. … and skill errors, errors of commission or omission.

338. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety.html
     September 01, 2023 - Clinician Psychological Safety in Reporting and Discussing Diagnostic Error Learning From Diagnostic Errors … Improve Diagnostic Safety Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors

339. Advancing Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advancing/index.html
     July 01, 2022 - While the IOM made recommendations to Congress for investigating medical errors and improving patient … The IOM noted that many of the errors in health care result from a culture and system that is fragmented … Later in 2000, under AHRQ leadership, that task force held a National Summit on Medical Errors and Patient … While the Institute of Medicine made recommendations to Congress for investigating medical errors and … and Patient Safety; Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors

340. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-1.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Introduction Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors … suggests it is imperative to focus on diagnostic safety in obstetrics to prevent and mitigate diagnostic errors