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541. AHRQ Impact Case Studies | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/index.html?page=3
     May 01, 2018 - Identifier: 2017-17 AHRQ Product(s): CANDOR Toolkit Topic(s): Patient Experience, Patient Safety, Medical Errors … Identifier: 2017-13 AHRQ Product(s): CANDOR Toolkit Topic(s): Patient Experience, Patient Safety, Medical Errors … Identifier: 2017-12 AHRQ Product(s): CANDOR Toolkit Topic(s): Patient Experience, Patient Safety, Medical Errors

542. Fallpxtool3O (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3o.docx
     January 01, 2008 - Total Errors: _______ SCORING*: 0-2 errors: normal mental functioning 3-4 errors: mild cognitive impairment … 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment * One more

543. Taxonomic Guidance for Remedial Actions (pdf file)
     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.

544. FileNewTemplate
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module9.pptx
     March 07, 2019 - Identify errors common to organizational change. … We then go to step five, which is called errors common to change. … Kotter identifies ways to institutionalize change and counter these errors. … Module 9 Summary In this module, you learned to: List Kotter’s Eight Steps of Change Identify errors … Identify errors common to organizational change.

545. Conclusions and Next Steps | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxchecklists-6.html
     September 01, 2020 - Can we develop checklists for diagnostic error reduction that focus on errors of execution rather than … errors of planning?

546. Conclusions and Next Steps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-6.html
     September 01, 2020 - Can we develop checklists for diagnostic error reduction that focus on errors of execution rather than … errors of planning?

547. Understand the Science of Safety Module Alternate Text | Agency for Healthcare Research and Quality
     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 .

548. Safety Climate on Hospital Units: A New Measure (pdf file)
     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.

549. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
     January 01, 2019 - By the end of the workshop, participants should: • Be introduced to an understanding of why errors … 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, … Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans To Enhance Safety … The best practices are designed to help alert hospitals and focus their efforts on errors that cause

550. Learn Module Alternate Text | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/learn/alt-text.html
     April 01, 2013 - Toolkit Demonstrate how to apply the CUSP Toolkit in a clinical environment Review the impact of errors … and patient harm and the underlying causes of errors Show how CUSP supports other quality … Toolkit Demonstrate how to apply the CUSP Toolkit in a clinical environment Review the impact of errors … and patient harm and the underlying causes of errors Slide 3 CUSP Supports Kotter’ … Slide 24 Examples of Defects or Errors That Affect Patient Safety Defect Intervention

551. Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda (pdf file)
     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?

552. After 20 Years of Improving America’s Healthcare, AHRQ Makes Bold Plans for Future Successes | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/bold-plans-future-successes.html
     October 01, 2019 - Medicine report that concluded between 44,000 and 98,000 people die each year from preventable medical errors … Reducing diagnostic errors An estimated 12 million people per year are affected by diagnostic errors … Our initial work should focus on the three largest areas of diagnostic errors: cancer, vascular conditions

553. What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
     January 01, 2003 - One drawback of the IOM report is that its conclusions regarding the cost of medical errors were not … In all our GLM regressions, the robust standard errors were estimated using the Huber/White sandwich … Standard errors are in parentheses. **Significantly different from zero at the 99% level. … Standard errors are in parentheses. **Significantly different from zero at the 99% level. … In fact, we did not consider drug-related errors, diagnostic errors, and errors in choice of therapy

554. AHRQ Impact Case Studies | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/index.html?page=4
     June 01, 2017 - Hospital Date: June 2017 Tennessee Medical Center Uses AHRQ Tools to Reduce Infections, Medical Errors … Events (ADE), Healthcare Costs, Healthcare-Associated Infections (HAIs), Hospital Readmissions, Medical Errors … Identifier: 2016-20 AHRQ Product(s): CANDOR Toolkit Topic(s): Patient Experience, Patient Safety, Medical Errors

555. Final Progress Report: Medications at Transitions and Clinical Handoffs (MATCH) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/15886-Noskin-draft-1.pdf
     March 01, 2008 - Purpose (Objectives of the study) It has been estimated that, in the US alone, medication errors cause … 7000 or more deaths per year.1 Nearly 40% of medication errors occur in the prescribing phase,2 and … Pharmacist participation in medical rounds reduces medication errors. … Massachusetts Coalition for the Prevention of Medical Errors (MCPME). … Medication reconciliation: a practical tool to reduce the risk of medication errors.

556. Patient Safety Executive Walkarounds (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Graham.pdf
     April 01, 2004 - high organizational priority, and (2) learn from direct care staff and physicians about near misses, errors … This culture must not only address strong accountability, but also must clinicians to report errors … The walkarounds have increased the reporting of actual errors and “near misses,” which has provided … ; it also is important to identify and report potential causes of errors before they occur. … In: Reducing medical errors and improving patient safety.

557. Clinical Pharmacists in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-fairbanks_20.pdf
     February 21, 2008 - medication errors are a significant contributor to errors in the ED, as well as in the inpatient setting … to occur, and second, “absorb” errors that do occur. … Medication errors in emergency department settings – 5 year review [abstract]. … Patient concerns about medical errors in emergency departments. … Variables associated with medication errors in pediatric emergency medicine.

558. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
     June 18, 2008 - ” PCA pumps with continuous respiratory monitoring and results achieved in significant programming errors … Numerous factors can lead to opioid-related RD: prescribing errors, PCA pump programming errors, “PCA … Part II: How to prevent errors. ISMP Medication Safety Alert; 2003 July 24. 4. … Part I: How errors occur. ISMP medication safety alert; 2003 July 10. … Design flaw predisposes Abbott Lifecare PCA Plus II pump to dangerous medication errors.

559. AHRQ Hospital Survey on Patient Safety Culture: Items and Dimensions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospital-survey-items.pdf
     July 25, 2017 - 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 (Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly

560. Health Care Simulation to Advance Safety: AHRQ Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/factsheets/errors-safety/simulproj15/simulation-brief.pdf
     February 01, 2015 - September 2011. http://www.ahrq.gov/research/findings/factsheets/errors-safety/simulproj.pdf. 20.