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41. Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/managing-interruptions-improve-diagnostic-decisionmaking.pdf
    December 29, 2022 - Received September 8, 2022 Accepted December 29, 2022 with a significant increase in medication errors … One study found that interrupted radiology residents were 12% more likely to have made diagnostic errors … Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. … Checklists to reduce diagnostic errors. Acad Med 2011;86(3):307–313. 26. … Are interventions to reduce interruptions and errors during medication administration effective?

42. Peer Review at AHRQ - Study Sections | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/funding/process/study-section/peerrev.html
    March 01, 2024 - It reviews applications relating to identifying risks and hazards that lead to medical errors and identifying … The research findings and products encompass providing information on the scope and impact of medical errors … healthcare associated infections; and examining effective ways to make system-level changes to help prevent errors … Dissemination and translation of research findings and methods to reduce medical errors, examining effective … ways to make system-level changes to help prevent errors, and developing, testing and evaluating various

43. Introduction Instructor Guide – PDF (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/longtermcare/module1/ts2-0ltc_module1_ig_intro.pdf
    January 01, 2007 - • How can we prevent errors? … It was determined that 43 percent of errors resulted from problems with team coordination. … • How can we prevent errors? • How can we prevent errors? … It was determined that 43 percent of errors resulted from problems with team coordination. … It was determined that 43 percent of errors resulted from problems with team coordination.

44. Understand the Science of Safety for Perinatal Safety (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
    May 01, 2017 - • In 1999, 44,000 to 99,000 people die from medical errors in hospitals each year. … SAY: Errors occur within the health care setting because health care professionals are human, and … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … In analyzing how errors occur, frontline providers must recognize the scientific nature of medicine

45. Making Healthcare Safer IV | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/research/findings/making-healthcare-safer/mhs4/index.html
    April 01, 2024 - I, II, and III have shown a positive impact of patient safety practices on the reduction of medical errors … evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors … evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors … Deprescribing Report Protocol Computerized Clinical Decision Support To Prevent Medication Errors

46. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/diagnostic-safety/workgroup/index.html
    March 01, 2024 - These reports bring attention to the specific problem of diagnostic errors and their effect on the quality … Goal 8 is to provide dedicated funding for research on the diagnostic process and diagnostic errors. … Federal agencies to develop a coordinated research agenda on the diagnostic process and diagnostic errors

47. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
    July 01, 2023 - In 1999, 44,000 to 99,000 people die from medical errors in hospitals each year. … Slide 4: How Can These Errors Happen? … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science. … Errors also occur because systems frequently do not catch mistakes before they reach the patient.

48. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/patient-safety/reports/liability/crane.html
    August 01, 2017 - Barriers to reporting near-miss errors include the additional workload burden imposed by a reporting … Factors that influence how students and residents learn from medical errors. … How surgeons disclose medical errors to patients: a study using standardized patients. … Lost opportunities: how physicians communicate about medical errors. … A preliminary taxonomy of medical errors in family practice.

49. Guide for Developing a Community-Based Patient Safety Advisory Council | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncilref.html
    April 01, 2018 - Institute of Medicine, Preventing Medication Errors , Quality Chasm Series. … Medication Errors . 2nd edition. Washington, DC: American Pharmacists Association; 2007. … Partnering with Patients to Reduce Medical Errors .Chicago: American Hospital Association Press; 2004 … Preventing medical errors: Communicating a role for Medicare beneficiaries.

50. Peer Review: Study Section Descriptions | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/funding/process/study-section/peerdesc.html
    July 01, 2017 - It reviews applications relating to identifying risks and hazards that lead to medical errors and identifying … The research findings and products encompass providing information on the scope and impact of medical errors … healthcare associated infections; and examining effective ways to make system-level changes to help prevent errors … Dissemination and translation of research findings and methods to reduce medical errors, examining effective … ways to make system-level changes to help prevent errors, and developing, testing and evaluating various

51. Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/research/findings/studies/index.html
    January 01, 2024 - Diagnostic errors in hospitalized adults who died or were transferred to intensive care. … Keywords: Diagnostic Safety and Quality, Medical Errors, Hospitals, Inpatient Care, Quality of Care, … This paper describes the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study, whose aim … was to define the prevalence and underlying causes of diagnostic errors (DEs) in patients who die in … Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.

52. New Toolkit Can Improve Post-Surgery Complications and Enhance Patient Recovery | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/news/newsletters/e-newsletter/870.html
    June 01, 2023 - Grantee Profile on Kathleen Walsh, M.D., M.Sc., Highlights Work To Prevent Pediatric Medication Errors … Grantee Profile on Kathleen Walsh, M.D., M.Sc., Highlights Work To Prevent Pediatric Medication Errors … Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Medication errors that occur outside the hospital can be lethal for children with chronic conditions, … Walsh has identified factors that contribute to medication errors and injuries in children with chronic

53. Resources | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/questions/resources/index.html
    November 01, 2020 - My Questions for This Visit 20 Tips To Help Prevent Medical Errors Next Steps After Your … for This Visit Prioritize questions while in the waiting room.  20 Tips to Help Prevent Medical Errors … Learn to prevent medical errors that can occur anywhere in the health care system and can involve medicines

54. Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/research/publications/search.html?page=2
    February 01, 2021 - instance, checklists have been successful in preventing hospital-acquired infections and preventing errors … The use of checklists has also been recommended as a tool to reduce diagnostic errors. … Diagnostic errors are frequent and often have severe consequences but have received little attention … provide knowledge and recommendations to encourage HCOs to begin to identify and learn from diagnostic errors

55. Identifying Strategies to Improve Medication Safety at Home | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/funding/grantee-profiles/grtprofile-xiao.html
    November 01, 2022 - Medication errors that occur at home, especially during transitions of care such as patient discharge … The preventable harms for these medication errors include adverse drug events (ADEs), unscheduled hospital … There is an increased potential for medication errors as more responsibilities of medication management … Xiao identified frequent errors that occurred during the placement of central lines or central venous

56. FileNewTemplate
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module9.pptx
    March 07, 2019 - Identify errors common to organizational change. … We then go to step five, which is called errors common to change. … Kotter identifies ways to institutionalize change and counter these errors. … Module 9 Summary In this module, you learned to: List Kotter’s Eight Steps of Change Identify errors … Identify errors common to organizational change.

57. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
    January 01, 2022 - , MPH*† Objectives: A lack of consensus around definitions and reporting standards for diagnostic errors … A lack of consensus around definitions and reporting standards for diagnostic errors limits the extent … Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.

58. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-mar2023.pdf
    July 14, 2023 - • EPC Program o Released the final report Diagnostic Errors in the Emergency Department: A Systematic … CDC • Division of Laboratory Systems o Health Equity and Diagnostic Errors: DLS envisioned and is … /grants/guide/rfa-files/RFA-HS-23-011.html https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency … /research https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency/research https:// … • Preventable Harm From Pediatric Outpatient Medication Errors: Measure Development o Project

59. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
    January 01, 2024 - Potential problems include medication errors, falls, infections, procedural complications, management … errors, diagnostic errors, lack of adequate monitoring, and lack of timely follow-up care. … human factors experts, and systems engineers—who developed an approach for investigating diagnostic errors

60. Hospital Survey on Patient Safety Culture Version 2.0: Composites and Items (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
    August 01, 2019 - When staff make errors, this unit focuses on learning rather than blaming individuals. A13. … 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. C2. … When errors happen in this unit, we discuss ways to prevent them from happening again. C3.