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201. Agency for Healthcare Research and Quality
     www.talkingquality.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

202. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.talkingquality.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.

203. Glossary | Agency for Healthcare Research and Quality
     www.talkingquality.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

204. Nursing Home Resources | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/es/nursing-home/resources/search.html?page=8
     January 01, 2022 - presentation on National Healthcare Safety Network reporting describes commonly observed reporting errors … Healthcare Safety Network COVID-19 module to improve data accuracy; and describes how to correct reporting errors

205. 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.talkingquality.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

206. TeamSTEPPS for Office-Based Care: Mutual Support | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/teamstepps/officebasedcare/module6/office_support-ig.html
     September 01, 2015 - Mutual support provides a safety net to help prevent errors, increase effectiveness, and minimize strain … support in which it is expected that assistance will be actively sought and offered as a way to reduce errors … corrective action to raise the concern and allow fellow team members the opportunity to check or correct errors … use advocacy and assertion has been frequently identified as a primary contributor to the clinical errors

207. TeamSTEPPS Fundamentals Course: Module 3. Communication | Agency for Healthcare Research and Quality
     www.talkingquality.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.

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

209. Job Aid: Introduction to Quality Improvement (pdf file)
     www.talkingquality.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.

210. Job Aid: Process Mapping (pdf file)
     www.talkingquality.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

211. AHRQ's 35th Anniversary | Agency for Healthcare Research and Quality
     www.talkingquality.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

212. Just Culture Webcast Closing (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-3-closing.pdf
     June 01, 2017 - Just Culture Webcast Closing Updating the Hospital Survey and Nonpunitive Response to Error • HSOPS 2.0 – Conducting cognitive testing and a pilot study – Version 2.0 to be released in early 2018 – Revising the Nonpunitive Response to Error composite to reflect Just Culture concepts 31 Nonpunitive Response to …

213. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
     www.talkingquality.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.

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

215. TeamSTEPPS® Rapid Response Systems Guide | Agency for Healthcare Research and Quality
     www.talkingquality.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

216. TeamSTEPPS 2.0 | Agency for Healthcare Research and Quality
     www.talkingquality.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

217. Just Culture Webcast Intro (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-1-intro.pdf
     November 09, 2016 - Just Culture Webcast Intro Using Just Culture to Improve Hospital Survey on Patient Safety Culture Results Webcast November 9, 2016 1:00-2:00 ET Presented by Westat under contract to the Agency for Healthcare Research and Quality Need Help? • No sound from computer speakers? – Join us by phone: 855-442-57…

218. Overview | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/guide-overview.html
     May 01, 2017 - which a punitive response to error prevails to a culture of safety—a learning environment in which errors … are treated as an opportunity to learn about root causes and prevent future errors and risks of harm

219. How To Use the Toolkit for Improving Perinatal Safety | Agency for Healthcare Research and Quality
     www.talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/how-to-use.html
     July 01, 2023 - this toolkit to create or enhance a culture of patient safety can significantly reduce preventable errors

220. Action Planning for the SOPS Surveys-Results (pdf file)
     www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-yount-sops-action-planning-tool.pdf
     June 01, 2019 - Action Planning for the SOPS Surveys-Results 31 Results to Action: An Action Planning Example Naomi Yount, PhD Senior Study Director, User Network for the AHRQ Surveys on Patient Safety Culture (SOPS) Westat 1. What areas do you want to focus on for improvement? • Review your percent positive scores on the s…