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601. Improving Your Laboratory Testing Process Toolkit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-toolkit.pdf
     December 01, 2017 - Errors in managing tests are more common than most of us realize. … Addressing the system can reduce errors. Figure 1. … Medical testing errors in this office do not harm patients. 9. … Providers and staff openly discuss causes and effects of errors. 10. … Reduce errors in delayed notification of lab results.

602. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-pfe.pdf
     January 01, 2023 - Patient reporting of medical errors and near misses; 2. … Key Findings/Impact: Among patients with errors at baseline, 59.3 percent of errors were resolved by … errors of omission (failure to intensify therapy when indicated) (p > 0.05). … and rated likelihood of medical errors. … Most recommended actions for preventing medical errors were viewed as effective.

603. Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Devine_83.pdf
     April 06, 2008 - quality of care; computerized provider order entry (CPOE) systems are believed to reduce medication errors … systems and introduces unpredicted and unintended consequences, including the generation of new types of errors … , thus minimizing the occurrence of prescription-related medication errors. … Generation of new kinds of errors. 8. Changes in the power structure. 9. … Role of computerized physician order entry systems in facilitating medication errors.

604. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
     April 22, 2004 - Alper Abstract Many articles in the medical literature state that medical errors are the result of … From this perspective, all medical errors and adverse events are somebody’s fault. … This fork was inspired by research that uncovered a disturbing numbers of errors in health care.10, … Medication errors observed in 36 health care facilities. … Medication errors and pediatric inpatients. JAMA 2001 Apr;285(16):2114–20. 27.

605. Voluntary Hospital Coalitions to Promote Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rask.pdf
     January 01, 2004 - the planning stages well before the Institute of Medicine published its landmark report on medical errors … PHA provides both leadership and support for reducing errors pertinent information. … use (SMU) program The SMU program, which focuses on reducing the frequency of medication- related errors … , and develops an improvement plan for at least one of those errors. … PHA provides both leadership and support for reducing errors << /ASCII85EncodePages

606. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
     May 01, 2011 - Scenarios for second-victims: Patient or family “connects” with staff member Pediatric cases Medical errors … Module 6 7 As referenced in Module 3, this diagram shows the distinction between adverse events and errors … , and recognizes that not all adverse events are medical errors, and not all medical errors are adverse … Therefore, it is important to recognize the distinction between medical errors and adverse events, as … AHRQ Primer: Support for Clinicians Involved in Errors and Adverse Events (Second Victims) Wachter RM

607. Ldusafety Facguide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
     May 01, 2017 - presentation, we will do the following: Describe the rationale for the use of checklists for reducing errors … Errors associated with schematic tasks are labeled “slips” and occur because of lapses in concentration … Errors associated with failures of attentional behavior are labeled “mistakes” and often occur because … Most errors in health care are slips rather than mistakes. … Checklist effectiveness for reducing errors can be enhanced when— they are created or adapted to meet

608. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/brock.html
     August 01, 2017 - The first component aimed to reduce medical errors by improving team communication through adoption of … Patients' and physicians' attitudes regarding the disclosure of medical errors. … Risk managers, physicians, and disclosure of harmful medical errors. … Choosing your words carefully: how physicians would disclose harmful medical errors to patients. … U.S. and Canadian physicians' attitudes and experiences regarding disclosing errors to patients.

609. Hospital Survey on Patient Safety Culture: Background and Information for Translators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/infotranshsops.pdf
     September 01, 2009 - 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 (More about this dimension: In a nonpunitive environment, when a mistake … Nonpunitive Response to Errors

610. The Science of Improving Patient Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
     March 01, 2009 - 62,000 deaths from central line-associated blood stream infections per year8 4 4 How Can These Errors … participates in rounds A point-of-care pharmacist or one who participates in rounds reduces prescribing errors … A look into the nature and causes of human errors in the intensive care unit.

611. Engaging Patients and Families in Their Health Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/patients-families/patient-family-engagement/index.html
     April 01, 2018 - This toolkit is designed to help staff actively engage patients and their care partners to prevent errors … effectiveness reviews that cover health topics suggested by the public. 20 Tips to Help Prevent Medical Errors … Other Resources Question Builder 20 Tips To Help Prevent Medical Errors Patients and Providers

612. Making Healthcare Safer III: Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/exe-summary.html
     March 01, 2020 - issues, healthcare-associated infections, nursing-sensitive events, procedural events, and diagnostic errors … Diagnostic Error: Peer Review Diagnostic errors Diagnostic discrepancy rates 14 studies … Nonrandom peer review appears to be more effective at identifying diagnostic errors than random peer … Patient Identification Errors: Patient Identification Errors in the Operating Room Compliance … The harms include diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant

613. 2019 Hospital Survey Pilot Test Results Part II (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pilot-test-partii.pdf
     September 01, 2019 - We are informed about errors that happen in this unit. … We are informed about errors that happen in this unit. … We are informed about errors that happen in this unit. (C1) 64% 71% 2. … 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. (C1) 71% 65% 65% 65% 2.

614. Labor and Delivery Unit Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety-fac-guide.html
     July 01, 2023 - presentation, we will do the following: Describe the rationale for the use of checklists for reducing errors … Errors associated with schematic tasks are labeled "slips" and occur because of lapses in concentration … Errors associated with failures of attentional behavior are labeled "mistakes" and often occur because … Most errors in health care are slips rather than mistakes. … Checklist effectiveness for reducing errors can be enhanced when— They are created or adapted to

615. Aurora Health Care Embraces AHRQ’s CUSP Method to Protect Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201524.html
     August 01, 2015 - safety team, and implementing "Fair and Just Principles," which establishes a non-punitive response to errors … Safety Culture, which helps hospitals assess staff perspectives on patient safety issues, medical errors

616. St. Joseph’s Hospital Improves Patient Safety Using AHRQ Tools | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201511.html
     May 01, 2015 - very good, we frequently worked with incorrect information from the home medication list, and these errors … During a two-month study, the pharmacy corrected 2.3 errors per patient. St.

617. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - strategies used by AHRQ to identify published literature in Patient Safety Net (PSNet): "medical errors … mistake*"[All Fields] OR "adverse event*"[All Fields] OR checklist ((medical error [mh] OR Diagnostic errors

618. Appendix F. Interventions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appf.html
     March 01, 2017 - Diagnostic error: safe and effective communication to prevent diagnostic errors No Yes … of diagnostic errors in primary care. … Recommendations to identify errors. … patients and providers to avoid medication errors in practice. … Speak Up: Help Prevent Errors in Your Care Yes Yes Strong Speak-Up!

619. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - The traditional approach assumed that well-trained, conscientious practitioners do not make errors. … or equipment—result from “latent” errors, as demonstrated by James Reason.3 Latent errors are upstream … The notion that sharing information about medical errors was essential for effective patient safety … Additionally, increased media exposure of preventable medical errors raised troubling questions that … Patients’ and physicians’ attitudes regarding the disclosure of medical errors.

620. The Challenge and Potential for Assuring Quality Health Care for the 21st Century | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/quality-measures/21st-century/index.html
     June 01, 2018 - Misuse of Services: Errors in health care delivery lead to missed or delayed diagnoses, higher costs … Based on this study, researchers estimated that preventable errors in hospital care led to 180,000 deaths … Moreover, there is still an unacceptable rate of errors; one study estimates that preventable errors … Lucian Leape of Harvard School of Public Health has estimated that preventable errors in hospital care … Medication Errors .