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  1. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
    May 05, 2008 - Introduction Medical errors have been recognized as a relatively common and potentially avoidable cause … We hypothesized that: (1) communication errors commonly occur during the postoperative handoff process … In health care, for example, this may involve new methods to detect medication errors. … A look into the nature and causes of human errors in the intensive care unit. … Residents’ suggestions for reducing errors in teaching hospitals.
  2. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/125-cusp-science-safety.pptx
    April 01, 2025 - 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. … Learn from mistakes (analyze communication errors and take steps to guard against the same future mistake … Due to psychological safety, there is no risk when people report their errors and near-misses.
  3. www.ahrq.gov/sops/international/hospital/translators-version-2.html
    October 01, 2024 - When staff make errors, this unit focuses on learning rather than blaming individuals. … More about this item: When staff make any errors or mistakes, supervisors/managers don’t immediately … 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. 
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
    January 01, 2025 - The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis … Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology Martin November, … Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS … xv Using Data Mining to Predict Errors in Chronic Disease Care Ryan M. … xviii Using Home Visits to Understand Medication Errors in Children Kathleen E.
  5. www.ahrq.gov/hai/cusp/modules/understand/science-safety-slides.html
    July 01, 2018 - How Can These Errors Happen? Slide 6. The Science of Safety Slide 7. … an adverse event. 3, 4 44,000 to 99,000 people die in hospitals each year as the result of medical errors … line-associated blood stream infections per year. 8 Return to Contents   Slide 5: How Can These Errors … A look into the nature and causes of human errors in the intensive care unit. … http://www.ahrq.gov/research/findings/factsheets/errors-safety/haicusp/ . 9.
  6. www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
    January 01, 2024 - , wrong patient and wrong drug data entry errors, prescription filling errors, and dispensing errors … Factors related to errors in medication prescribing. … Dispensing errors and counseling quality in 100 pharmacies. … Preventing medication errors: quality chasm series. … Institute of Medicine, Committee on Identifying and Preventing Medication Errors.
  7. www.ahrq.gov/evidencenow/tools/ehr-reports.html
    November 01, 2018 - involving care teams in validating data, and the ability of checklists to help detect both inclusion errors … (including patients in the measure that should not have been included) and exclusion errors (patients
  8. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
    July 18, 2008 - International taxonomy of medical errors in primary care-Version 2. … A preliminary taxonomy of medical errors in family practice. … Preventing medication errors: Quality chasm series. … Strategies to reduce medication errors in ambulatory practice. … EPITOME program educates patient to help reduce medication errors.
  9. www.ahrq.gov/sites/default/files/2024-01/devine-report.pdf
    January 01, 2024 - Her goal was to study the impact of a CPOE system on medication errors and ADEs in the ambulatory care … Devine designed a study to evaluate the impact of The Everett Clinic’s CPOE system on medication errors … The objective was to evaluate the effect of a basic, ambulatory CPOE system on medication errors and … , perhaps due to few errors in this category. … Characterization of prescribing errors in an internal medicine clinic.
  10. www.ahrq.gov/sites/default/files/2024-01/muller-report.pdf
    January 01, 2024 - During its FY06, LHS documented 2,646 reported medication errors. … Figure 1: Total medication errors at admission Mean errors at admission 0 0.5 1 1.5 2 2.5 3 … errors at discharge Mean errors at discharge 0 1 2 3 4 5 6 Pre Post Implementation period … M ea n # of e rr or s Mean d/c errors b. … The total number of medication errors improved after the intervention as well.
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Mottur.pdf
    June 01, 2005 - The medication errors module, in turn, presents proven strategies to prevent the most common medication … errors by, for example, substituting computerized physician order entry systems for handwriting. … By recognizing what went wrong, physicians can avoid similar errors in the future. … Systems and medication errors modules received the highest approval rating from the audience. … Views of practicing physicians and the public on medical errors.
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Dickerman_84.pdf
    June 04, 2008 - substantial evidence suggests that the design of hospital physical environments contributes to medical errors … A recent study correlated the relationship of medication errors to lighting levels. … As lighting intensity approaches 1,500 lux,7 the incidence of medication errors dramatically decreases … The Scope of the Problem Medical mistakes, or errors, in which the design of the physical environment … Illumination and errors in dispensing. Am J Hosp Pharm 1991; 48 2137-45. 8.
  13. www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-older-adults.pdf
    January 17, 2024 - Older adults are at higher risk for diagnostic errors than younger adult populations for multiple reasons … Examples of case reports with diagnostic errors of common health concerns in older adults Authors … This scenario places older adults with MCCs at higher risk for diagnostic errors. … Developing policies to support the voluntary reporting of diagnostic errors and near-misses. … and testing of interventions to reduce diagnostic errors has been lagging.
  14. www.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety.html
    April 01, 2019 - These errors occur in all settings of care, contribute to about 10 percent of patient deaths, and are … Substantial effort is needed to identify research priorities, including how to measure and reduce diagnostic errors
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
    December 23, 2004 - Those that result from errors in the formation of the intent. 2. … While his study concerned speech, Norman acknowledged that the errors also applied to other activities … Knowledge-based errors can be due to information problems (information not being sought, information … being assumed, or failure to realize information is needed) or inference errors, when conditions or … Human errors. A taxonomy for describing human malfunction in industrial installations.
  16. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-culture-survey-brazil-intro.html
    August 01, 2024 - An analysis of 276 severe and catastrophic adverse events from 2016 to 2022 found that diagnostic errors … create an initial approach to developing and implementing a program to recognize and address diagnostic errors
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
    January 01, 2004 - National Summit on Medical Errors and Patient Safety Research. … Research agenda: medical errors and patient safety. … Factors contributing to medication errors: a literature review. … Workload and environmental factors in hospital medication errors. … Perceived barriers in reporting medication administration errors.
  18. www.ahrq.gov/sites/default/files/wysiwyg/topics/managing-interruptions-improve-diagnostic-decisionmaking.pdf
    December 29, 2022 - Received September 8, 2022 Accepted December 29, 2022 with a significant increase in medication errors … One study found that interrupted radiology residents were 12% more likely to have made diagnostic errors … Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. … Checklists to reduce diagnostic errors. Acad Med 2011;86(3):307–313. 26. … Are interventions to reduce interruptions and errors during medication administration effective?
  19. www.ahrq.gov/sites/default/files/2025-03/tanner-report.pdf
    January 01, 2025 - Two major types of diagnostic errors can be made, incorrect diagnoses and diagnostic delays, and the … Below, we define how each of these types of diagnostic errors is defined and operationalized in our
  20. www.ahrq.gov/hai/cusp/modules/understand/alt-text.html
    July 01, 2018 - suffers an adverse event3,4 44,000 to 99,000 people die in hospitals each year as the result of medical errors … from central line-associated blood stream infections per year8   Slide 5 How Can These Errors … Having a point-of-care pharmacist or a pharmacist who participates in rounds can help reduce prescribing errors … A look into the nature and causes of human errors in the intensive care unit. … https://www.ahrq.gov/research/findings/factsheets/errors-safety/haicusp/index.html .

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