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141. Silence A Commentary | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/patient-safety/reports/liability/silence.html
     August 01, 2017 - Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006. 2. … Disclosing medical errors to patients: It’s not what you say, it’s what they hear. … Collaboration with regulators to support quality and accountability following medical errors: The Communication

142. TeamSTEPPS® for Office-Based Care - Team Performance Observation Tool (pdf file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/handouts/tmpot.pdf
     December 09, 2015 - Monitors fellow team members to ensure safety and prevent errors c.

143. AHRQ Safety Program for Perinatal Care: Board Checklist (doc file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/supporting/board-checklist.docx
     May 01, 2017 - Discuss major patient safety events/errors that have occurred in the most recent timeframe to show that

144. Understand the Science of Safety for Perinatal Safety | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-slides.html
     July 01, 2023 - , it was estimated that 44,000 to 99,000 people die in hospitals each year as the result of medical errors … each year, and the cost of HAIs is $28 billion to $33 billion per year. 5 Slide 4: How Can These Errors … Department of Health and Human Services makes no warranties regarding errors or omissions and assumes

145. Primary Care Practice-Based Research Networks | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/research/findings/factsheets/primary/pbrn/index.html
     October 01, 2018 - Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets Medical Errors … during a pandemic influenza event. 4 Field testing of a new ambulatory care electronic Medication Errors … Field test results of a new ambulatory care Medication Errors and Adverse Drug Events Reporting System

146. Tool 3: The Share Approach Overcoming Communication Barriers With Your Patients: A Reference Guide for Health Care Providers (pdf file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-3/share-tool3.pdf
     April 01, 2014 - That choice is more likely to result in misunderstandings and medical errors. … Using untrained staff to interpret has been shown to lead to clinically significant medical errors. … may be unfamiliar with technical or scientific language. › They may inadvertently commit interpretive errors

147. Appendix D: Methods | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/health-literacy/professional-training/lepguide/app-d.html
     September 01, 2020 - from a diverse range of hospitals on best practices for preventing, reporting, and documenting medical errors

148. Health Literacy Publications | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/health-literacy/publications/index.html
     January 01, 2024 - Poor Oral Health Literacy: Why Nobody Understands You (2015) Identifying and Preventing Medical Errors … (PDF) Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance

149. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/patient-safety/reports/liability/neumiller.html
     August 01, 2017 - reduce safety risks to patients, health systems expend considerable resources to prevent medication errors … hospital setting. 1-3 Increasingly, inpatient medication risk management efforts focus on preventing errors … an ambulatory care population, there were 5.24 discrepancies identified per patient, and medication errors … Institute of Medicine, Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J … Medication Errors: Quality Chasm Series (pp. 1-25), Washington DC: National Academies Press; 2007.

150. Section 2: Explanation of Key Concepts and Tools | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/teamstepps-program/curriculum/situation/tools/index.html
     June 01, 2023 - maintain awareness of workload spikes and stress levels among themselves that may lead to diagnostic errors … During the diagnostic process, situation awareness provides an important way to prevent diagnostic errors … Helping avoid errors that put patients at risk.

151. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072320.pdf
     November 06, 2020 - Taxonomy of diagnostic errors that could occur in the COVID-19 era, including false negatives and other

152. Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/patient-safety/reports/liability/waever.html
     August 01, 2017 - and transparency; and (3) inspiring individual clinicians to engage in mindful practice, to report errors … Clinicians experience errors and near misses as deeply personal and painful events. 23,24 Even if no … multiple-aspects of patient safety culture are differentially related to indicators of safety, disclosure of errors … dimensions (e.g., communication openness, degree to which there is an orientation toward learning from errors … Saber Tehrani AS, Lee H, Mathews SC, et al. 25-Year summary of U.S. malpractice claims for diagnostic errors

153. AHRQ Accelerates Efforts To Advance Health Equity | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/news/newsletters/e-newsletter/907.html
     April 01, 2024 - Research has shown that improved teamwork reduces the number of medical errors and improves patient safety … Articles featured this week include: Transfusion-related errors and associated adverse reactions and

154. AHRQ Views: A Unique Effort To Advance Care for People Living With Long COVID | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/news/newsletters/e-newsletter/905.html
     March 01, 2024 - Medical misadventures as errors and mistakes and motor vehicular accidents in the disproportionate burden … Telemedicine vs telephone consultations and medication prescribing errors among referring physicians:

155. Hand Hygiene Observational Audit Tracking Tool (xls file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
     December 01, 2021 - Hand Hygiene Observational Audit Tracking Tool Ref January 2021 KS A:B Admin February 2021 MO D:E RN March 2021 SC G:H LPN/LVN April 2021 VA J:K Med Aides May 2021 CNA June 2021 EVS July 2021 Maintenance August 2021 Dietary September 2021 SW-Rec October 2021 Rehab November 20…

156. Course Evaluation | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/teamstepps/officebasedcare/handouts/courseeval.html
     December 01, 2015 - Describe the impact of errors and why they occur 1 2 3    2. … Identify errors common to organizational change 1 2 3    3.

157. Guide for Developing a Community-Based Patient Safety Advisory Council | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncil2.html
     April 01, 2018 - There is a new wave of consumers who have heard stories of or actually experienced errors, mistakes, … Institute of Medicine, Preventing Medication Errors, Quality Chasm Series .

158. SOPS Nursing Home Survey: What You Need To Know - Nicholas Castle, Ph.D., M.H.A., FGSA (pdf file)
     www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
     January 01, 2006 - Hospitals ►Moving, Transferring, or Lifting Residents ►Medication errors ►Falls ►Pressure ulcers ►Sanitation

159. Top Five Conditions Most Often Misdiagnosed in Emergency Departments | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/data/infographics/misdiagnosed-ed.html
     February 01, 2023 - Emergency Departments (PDF, 3.6 MB) Source:  https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency

160. Patient Narratives Can Catalyze Staff Improvement and Bolster Survey Scores | Agency for Healthcare Research and Quality
     www.healthcare411.ahrq.gov/news/newsletters/e-newsletter/900.html
     February 01, 2024 - Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events . … Health literacy-informed communication to reduce discharge medication errors in hospitalized children