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441. Final Progress Report: The National Quality Forum Annual Meeting 2004 (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/kizer2-report.pdf
     January 01, 2025 - Unlike other areas of the hospital, medication errors in the operating room occur infrequently, but … of verbal orders, and the absence of patient unit-dosing provide opportunity for the reduction of medication … errors in operating rooms.

442. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses6.html
     August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department References Previous Page   Table of Contents Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Introduction The Theory of Distributed Cognition Nurses' Role…

443. Healthcare Spending Higher Among Adults Who Had Adverse Childhood Experiences | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/926.html
     August 01, 2024 - Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity

444. Methods (continued, 3) | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3b.html
     July 01, 2018 - complemented by several peer-reviewed articles that discussed techniques for educating patients about medication … errors or methods for reconciling medication lists. 192 , 195,196 , 221,222 For example, in one randomized … post-implementation survey of nurses working with these patients, 29 percent reported that at least one medication … error was prevented because a patient or a family member identified a drug-related problem. 222 Another

445. Blood Thinner Pills: Your Guide to Using Them Safely (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/diagnosis-treatment/treatments/btpills/btpills.pdf
     September 01, 2015 - Many medication errors are found by patients. 3 Using Other Medicines Tell your doctor about every

446. Maine Groups Improve Care for Patients with Intellectual/Developmental Disabilities | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202201.html
     January 01, 2022 - Maine Groups Improve Care for Patients with Intellectual/Developmental Disabilities Search All Impact Case Studies January 2022 A partnership between the Maine Developmental Disabilities Council (MDDC) and two AHRQ-listed patient safety organizations (PSOs) is helping improve care for patients with intell…

447. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
     September 28, 2016 - improved educational and training materials for clinical staff • information technology that reduced medication … errors and improved data collection AHRQ AHRQ's reauthorizing legislation specified that the

448. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-5.html
     June 01, 2020 - Operational Measurement of Diagnostic Safety: State of the Science References Previous Page   Table of Contents Operational Measurement of Diagnostic Safety: State of the Science Introduction Special Considerations for Measurement of Diagnostic Safety Getting Ready for Measurement: Overcoming …

449. Implement-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.docx
     May 01, 2017 - AHRQ Safety Program for Perinatal Care Implement Teamwork and Communication for Perinatal Safety Implement Teamwork and Communication for Perinatal Safety SAY: The Implement Teamwork and Communication module of the AHRQ Safety Program for Perinatal Care will help you understand the importance of effective communicatio…

450. Implement Teamwork and Communication for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/implement-fac-guide.html
     July 01, 2023 - Implement Teamwork and Communication for Perinatal Safety: Facilitator Guide AHRQ Safety Program for Perinatal Care Slide 1: Implement Teamwork and Communication for Perinatal Safety Say: The Implement Teamwork and Communication module of the AHRQ Safety Program for Perinatal Care will help you understa…

451. Mobile Text Messaging | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/healthit-ed-3.html
     February 01, 2021 - Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments Mobile Text Messaging Previous Page Next Page Table of Contents Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments Introduction Elect…

452. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
     August 01, 2025 - Diagnostic test errors appeared in 47% of reported events; medication errors appeared in 35.4%; and … by AHRQ Common Format criteria, are adverse events (e.g., falls, pressure injuries, infection, and medication … errors/adverse drug events, including inappropriate use).

453. The Science of Improving Patient Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
     March 01, 2009 - The Science of Improving Patient Safety 1 2 Describe the historical and contemporary context of the Science of Safety Explain how system design affects system results List the principles of safe design and identify how they apply to technical work and teamwork Indicate how teams make wise decisions when the…

454. Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/methods.html
     March 01, 2017 - the home were not regarded as addressing patient safety unless the falls were explicitly related to medication … errors or similar problems.

455. Final Progress Report: Pharmacist Technology for Nursing Home Resident Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lapane-report.pdf
     January 01, 2024 - Assessment Med Guide™ (GRAM™), in nursing facilities to improve medication safety Scope: Efforts to reduce medication … errors have focused on prescribing, dispensing, or medication administration; GRAM™ targets the monitoring … Many clinical informatics systems focus on the reduction of medication errors at the point of prescribing

456. 130-Ss-Swiss-Cheese-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
     April 01, 2025 - prevents infusions from running too fast is an example of a latent defect that could contribute to medication … errors.

457. Teamworknotes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamworknotes.docx
     June 02, 2025 - SAY: The “Implement Teamwork and Communication” module of the Comprehensive Unit-based Safety Program (or CUSP) Toolkit will help you understand the importance of effective communication and transparency, identify barriers to communication, and apply the effective teamwork and communication tools from CUSP and TeamSTEP…

458. “Safeware”: Safety-Critical Computing and Health Care Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Wears_75.pdf
     May 27, 2008 - Role of computerized physician order entry systems in facilitating medication errors.

459. Screener Items for the CAHPS Item Set for Children with Chronic Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/surveys-guidance/item-sets/children-chronic/screener.html
     April 01, 2022 - Screener Items for the CAHPS Item Set for Children with Chronic Conditions The CAHPS Item Set for Children with Chronic Conditions includes a five-item screener that is used during the analysis of the data to determine which responses to the questionnaire reflect the experiences of children with chronic conditi…

460. Final Progress Report: Reducing Risks by Engineering Resilience Into HIT for EDs (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/wears-report.pdf
     January 01, 2024 - Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors.