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81. Meeting Minutes, April 2019 | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/news/events/nac/2019-04-nac/nacmtg0419-minutes.html
    July 01, 2019 - Brady described AHRQ’s current efforts to improve diagnosis, that is, to reduce diagnostic errors in … More than 4 million U.S. citizens each year suffer severe consequences as a result of diagnostic errors … Brady stated that the Agency’s goal is to reduce the rate of diagnostic errors occurring each year in … A reduction of 1 million diagnostic errors in 1 year would potentially result in a savings of $500 million … It has identified a pool of individuals who have experienced diagnostic errors.

82. TeamSTEPPS for Office-Based Care: Change Management | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/teamstepps/officebasedcare/module9/office_mgmt.html
    September 01, 2015 - Act Slide 11: Produce Short-Term Wins Slide 12: Don’t Let Up Slide 13: Create a New Culture Slide 14: Errors … Identify errors common to organizational change. … Activity (continued) Step 4: Review Kotter’s Eight Steps of Change (5 minutes) Step 5: Discuss errors … Return to Contents Slide 14: Errors Common to Organizational Change Allowing for complacency.

83. Explicit and Standardized Prescription Medicine Instructions | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/health-literacy/improve/pharmacy/instructions.html
    September 01, 2020 - Instructions Explicit, standardized instructions improve patients’ understanding, and possibly reduce errors … To improve patients' understanding, and possibly reduce errors while improving adherence, AHRQ grantee … Studies have shown that errors are more likely with more complex regimens.

84. TeamSTEPPS for Office-Based Care: Change Management | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/teamstepps/officebasedcare/module9/office_mgmt-ig.html
    September 01, 2015 - Identify errors common to organizational change. … Errors Common to Change (5 Minutes): Ask participants what some of the common errors are when trying … Compare the errors to those found on slide 14 that accompanies page 14. … Return to Contents Errors Common to Organizational Change Say: Training is not a standalone … Kotter identifies ways to institutionalize change and counter these errors.

85. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
    www.innovations.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.

86. Hospitals and Health Systems | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/patient-safety/settings/hospital/resource/index.html
    August 01, 2022 - recommendations, and other resources for hospitals and hospital administrators to improve quality, reduce errors … Toolkits, recommendations, and other resources for long-term care facilities to improve quality, reduce errors

87. AHRQ Research Summit on Improving Diagnosis in Health Care | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety.html
    April 01, 2019 - These errors occur in all settings of care, contribute to about 10 percent of patient deaths, and are … Substantial effort is needed to identify research priorities, including how to measure and reduce diagnostic errors

88. Learn about CUSP | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/hai/cusp/modules/learn/index.html
    July 01, 2018 - Discusses the effects of errors and patient harm and the underlying causes of errors.

89. Hospital Survey on Patient Safety Culture Version 2.0 (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
    January 01, 2021 - When staff make errors, this unit focuses on learning rather than blaming individuals........... 1 … 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 ............................................ … When errors happen in this unit, we discuss ways to prevent them from happening again .. 1 2 3 4

90. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-110620.pdf
    March 11, 2021 - • Preventable Harm From Pediatric Outpatient Medication Errors: Measure Development: This project … The discussion included topic-specific comments around diagnostic errors related to health information

91. Patient Safety Tools | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
    June 01, 2022 - The strategies can help prevent harmful events such as medication errors, bed sores, and healthcare-associated … Guide for Hospitals focuses on how hospitals can better identify, report, monitor, and prevent medical errors … journal and forum on patient safety and health care quality that features expert analysis of medical errors … describe accomplishments between 1999 and 2004 by federally funded programs in understanding medical errors … Web: [ in English ] Web: [ en español ] 20 Tips to Help Prevent Medical Errors tells patients

92. AHRQ Pharmacy Health Literacy Center | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/health-literacy/improve/pharmacy/index.html
    January 01, 2024 - Medication errors are likely higher with patients with limited health literacy, as they are more likely … Medication errors are likely higher with patients with limited health literacy.

93. TeamSTEPPS® for Office-Based Care - TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/officebasedcare/handouts/teamattitude.pdf
    December 09, 2015 - Teams that do not communicate effectively significantly increase their risk of committing errors. … Poor communication is the most common cause of reported errors. 27.

94. TeamSTEPPS 2.0 Evidence Base: Situation Monitoring (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/ebsitmonitor.pdf
    January 01, 2013 - In fact, poor situation monitoring has been considered a contributor to clinical errors,9 whereas high … This can serve to reduce errors and thus enhance patient safety. … The potential for improved teamwork to reduce medical errors in the emergency department.

95. Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/programs/index.html?page=2
    April 28, 2024 - Research AHRQ offers toolkits, recommendations, and other resources to improve quality, reduce errors … toolkits, recommendations, and other resources for long-term care facilities to improve quality, reduce errors

96. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/patient-safety/resources/learning-lab/index.html
    February 01, 2024 - These include identification errors, delayed or missed diagnoses, redundant testing, treatment delays … or errors, medication errors, and unexpected clinical deterioration. … Bedside clinicians’ perceptions on the contributing role of diagnostic errors in acutely ill patient … Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study . … Providers' and Patients' Perspectives on Diagnostic Errors in the Acute Care Setting . 

97. Health Care Facility Design Safety Risk Assessment Toolkit | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html
    October 01, 2020 - facilities can minimize such safety problems as health care-associated infections, patient falls, medication errors … The toolkit: Targets six areas of safety—infections, falls, medication errors, security, injuries of

98. SOPS™ Health Information Technology (Health IT) Supplemental Items for Hospitals Webcast Transcript (pdf file)
    www.innovations.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast-transcript.pdf
    July 25, 2018 - First, by preventing errors and adverse events. … Gandhi, Slide 19 There's many ways we think about that prevention of errors piece, which was in the … These are the kinds of technologies that have the potential to really reduce errors significantly. … "I think the errors in the charting occur when people get in a hurry and copy and paste." … I notify the appropriate person of these errors."

99. AHRQ Stats: Hospital Admission Emergency Department Visits | Agency for Healthcare Research and Quality
    www.innovations.ahrq.gov/news/newsletters/e-newsletter/797.html
    January 01, 2022 - PICC Lines Safer   New Patient Safety Network Cases Offer Commentaries on Avoiding Severe Medical Errors … New Patient Safety Network Cases Offer Commentaries on Avoiding Severe Medical Errors Two new Web M … Web) case studies from AHRQ's Patient Safety Network (PSNet) include expert analyses of medical errors

100. Engaging Patients and Families in Their Health Care | Agency for Healthcare Research and Quality
     www.innovations.ahrq.gov/patient-safety/patients-families/index.html
     June 01, 2023 - 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