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181. Biosketches | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-biosketches.html
     September 01, 2016 - Goeschel was recently appointed to an Institute of Medicine committee focused on diagnostic errors in … He is also a pioneer in efforts to address diagnostic errors in medicine. … Pediatric and Adolescent Health and Health Care, and currently is part of the IOM Committee on Diagnostic Errors … Newman-Toker’s academic mission is to eliminate harms from diagnostic errors and maximize the accuracy … VA and AHRQ-funded patient safety research in improving the use of health IT and reducing diagnostic errors

182. Strategy 6C: OpenNotes | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/access/strategy6c-opennotes.html
     March 01, 2020 - read and amend their chart enhanced opportunities to: Detect serious inaccuracies and avoid medical errors … doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors

183. Patients & Consumers | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/patients-consumers/index.html
     August 01, 2018 - Patients and families who engage with health care providers ask good questions and help reduce the risk of errors

184. Linking to the AHRQ Website | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/policy/electronic/links/index.html
     March 01, 2021 - health research and statistics health information technology medical treatment effectiveness medical errors

185. Translating Research Into Practice | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/research/findings/factsheets/translating/index.html
     September 01, 2020 - Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets Medical Errors

186. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - individual performance may appear to resolve a case, it does not ensure the event won't happen again; human errors … Just Culture "People make errors, which lead to accidents. Accidents lead to deaths. … If we find out who made the errors and punish them, we solve the problem, right?  Wrong.

187. Primary Care-Based Efforts To Reduce Potentially Preventable Readmissions | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/patient-safety/settings/ambulatory/reduce-readmissions.html
     December 01, 2023 - readmissions are a major patient safety problem associated with adverse events such as prescribing errors

188. Patient Safety Research Summaries | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/patient-safety/research-summaries/index.html
     March 01, 2024 - Teamwork and Leadership (PDF, 1 MB): Research shows that improved teamwork reduces the number of medical errors

189. Glossary | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/questions/resources/glossary.html
     November 01, 2020 - My Questions for This Visit 20 Tips To Help Prevent Medical Errors Next Steps After Your … organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors

190. Systemic and Public Policy Changes Needed To Improve Care for Patients With Psychiatric Conditions and Substance Use Disorders | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/news/newsletters/e-newsletter/847.html
     January 01, 2023 - He has developed methods to measure and prevent errors in health information technology systems, including … The RAR Measure has facilitated a large body of patient safety research, including medication errors

191. Job Aid: Process Mapping (pdf file)
     www.cahps.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-process-mapping.pdf
     May 17, 2021 - When to use process mapping Use process mapping to help a practice remove waste and errors, make workflows

192. Job Aid: Introduction to Quality Improvement (pdf file)
     www.cahps.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-intro-qi.pdf
     May 18, 2021 -  Lean/Six Sigma focuses on eliminating errors and defects.

193. Research Findings & Reports | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/research/findings/index.html
     August 01, 2023 - Medical Errors and Patient Safety Quality Translating Research Into Practice Quality & Disparities

194. Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/research/findings/studies/index.html?page=1
     January 01, 2024 - Low-Income (171) Maternal Care (182) Medicaid (359) Medical Devices (71) Medical Errors … reports from an academic medical center (December 2020 to January 2021), identified near misses and errors … Results showed that among 35 near misses/errors, incident reports described contributing factors (mean … 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = … Medication: Safety, Medication, Patient Safety, COVID-19, Adverse Drug Events (ADE), Adverse Events, Medical Errors

195. TeamSTEPPS Fundamentals Course: Module 3. Communication | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/teamstepps/instructor/fundamentals/module3/igcommunication.html
     March 01, 2019 - 1995 and 2005, ineffective communication was identified as the root cause of 66 percent of reported errors … Information Exchange Strategies Say: A number of tools and strategies to potentially reduce errors … What communication errors were avoided? … Errors caused by misunderstood dosage amounts or drugs with similar sounding names were avoided.

196. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
     March 01, 2017 - used in combination with clinical or operational efforts to minimize harms such as falls, medication errors … misunderstandings and improve communication, the most significant contributing factor to prevent harm or errors … How were these human errors handled? 1. Griffith S. Just Culture, Healthcare Services Overview.

197. AHRQ's 35th Anniversary | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/cpi/about/35th-anniversary/index.html
     April 01, 2024 - toolkits, designed to help doctors, nurses, hospital managers, patients, and others reduce medical errors … disinfection interventions for reducing healthcare-associated infections, practices to prevent medication errors … On April 16, 2014, an AHRQ-funded study concluded that outpatient diagnostic errors affect 1 in 20 U.S

198. Minority Health | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/research/findings/factsheets/minority/index.html
     April 01, 2018 - Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets Medical Errors

199. TeamSTEPPS® Rapid Response Systems Guide | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/teamstepps/rrs/index.html
     March 01, 2019 - essential for the provision of quality healthcare and for the prevention and mitigation of medical errors

200. TeamSTEPPS 2.0 | Agency for Healthcare Research and Quality
     www.cahps.ahrq.gov/teamstepps/instructor/index.html
     August 01, 2022 - skills are essential to the delivery of quality health care and to preventing and mitigating medical errors