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441. Aetna Informs Members With AHRQ Materials | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/multicenter-0702-cp3-ockt.html
     October 01, 2014 - linked on Aetna's Web site: Five Steps to Safer Health Care. 20 Tips to Help Prevent Medical Errors … . 20 Tips to Help Prevent Medical Errors in Children. … Ways You Can Help Your Family Prevent Medical Errors. Quick Tips When Planning Surgery.

442. Appendix C: Using Solid Analytical Methods to Estimate Program Impacts | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/tools/pcmh/implement/appendix-c.html
     September 01, 2021 - multivariate analysis that controls for patient- and practice-level variables, and adjusting standard errors … Adjust Standard Errors for Clustering and Multiple Comparisons You must account for clustering when … There are also more formal ways to adjust standard errors for multiple comparisons. 20

443. Vermont Health Clinics Promote AHRQ’s Medication Safety Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202003.html
     June 01, 2020 - involves both health providers and patients is considered the "first line of defense against medication errors … Medication errors are common patient safety incidents in primary care, with rates ranging between 1 and … Medication safety issues include prescribing errors, contraindications, over- and under-prescribing,

444. Infographic Poster: Did you know...Patient safety issues in primary care are real. (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/patient-safety-issues.pdf
     May 21, 2020 - 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 visit efficiency by setting the visit agenda together with Be Prepared

445. Teaching Implementation Change Management | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/team/implement/teach-change.html
     February 01, 2024 - Identify errors common to organizational change. … Common Errors Display Slide 75, “Errors Common to Organizational Change.” … This slide lists common errors to avoid. … Errors Common to Organizational Change (5 Minutes) Ask participants what some of the common errors … Compare the errors to those presented in Slide 75.

446. 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

447. Final Progress Report: Factors That Enhance Diagnostic Imaging Safety in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/lacson-report.pdf
     January 01, 2025 - In order to more accurately elucidate errors related to diagnostic imaging, we also assessed several … In a human factors analysis of various information sources to inform diagnostic process errors, the … SCORE may help reduce errors resulting from diagnostic delays due to unscheduled exam orders. … Other Factors Contributing to Diagnostic Errors (Unscheduled Exams) 17. … Cognitive and system factors contributing to diagnostic errors in radiology. AJR Am J Roentgenol.

448. 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.

449. Scisafetynotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafetynotes.docx
     September 04, 2012 - Slide 4 SAY: Errors occur within the health care setting because people are fallible. … 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. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

450. ICU Clinical Decision-Making; Processes to Improve Catheter Insertion and Removal Choices; Science of Safety Concepts to Improve ICU Culture | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/icu-clinical-decision-making-slides.html
     December 01, 2017 - Recognize that teams make wise decisions with diverse and independent input Slide 31 Medical errors … Unfamiliar situations/new problem Using past solutions Equipment design flaws Communications errors … of Medicine) Basic Concepts in Patient Safety User-Centered Design Understanding how to reduce errors … Institute of Medicine) Basic Concepts in Patient Safety Anticipate the Unexpected Likelihood of errors … of error and should adopt the custom of automating cautiously Design for Recovery Assume that errors

451. CAUTI Indications
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/icu-clinical-decision-making-021115.pptx
     January 01, 2011 - Recognize that teams make wise decisions with diverse and independent input 30 Pat 30 31 Medical errors … User-Centered Design Understanding how to reduce errors depends on framing likely sources of error and … work hours, staffing ratios and sources of distraction Example: “Red Zones” to prevent medication errors … Design for Recovery Assume that errors will occur and design and plan for recovery by duplicating critical … patient care decisions should be available at the point of patient care 36 How Can These Errors

452. 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.

453. 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.

454. 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

455. Infographic Poster: Did you know...Patient safety issues in primary care are real. (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
     July 12, 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 visit efficiency by setting the visit agenda together with Be Prepared

456. 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.

457. Evaluation of Diagnostic Stewardship Implementation | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship7.html
     August 01, 2024 - diagnostic stewardship interventions improved diagnostic safety outcomes and reduced the risk of diagnostic errors … Other potential diagnostic safety outcomes include diagnostic errors in which testing-related factors … Diagnostic errors can be identified by reviewing a sample of records from the target population (e.g.

458. Pediatric Diagnostic Safety: State of the Science and Future Directions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-pediatric-safety.pdf
     September 01, 2023 - Identification, analysis, and reduction in diagnostic errors. … Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Pediatr. … Overcoming Diagnostic Errors in Medical Practice. J Pediatr. … Diagnostic errors in paediatric cardiac intensive care. Car- diol Young. … Cognitive Errors in Pediatric Emergency Medicine. Pediatr Emerg Care.

459. Understand the Science of Safety | Agency for Healthcare Research and Quality
     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.

460. Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/questions/resources/index.html
     November 01, 2020 - for This Visit Prioritize questions while in the waiting room.  20 Tips to Help Prevent Medical Errors … Learn to prevent medical errors that can occur anywhere in the health care system and can involve medicines