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461. 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.

462. SimCare: A Model for Studying Physician Decisionmaking Activity (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Dutta.pdf
     January 01, 2003 - SimCare: A Model for Studying Physician Decisionmaking Activity 179 SimCare: A Model for Studying Physician Decisionmaking Activity Pradyumna Dutta, George R. Biltz, Paul E. Johnson, JoAnn M. Sperl-Hillen, William A. Rush, Jane E. Duncan, Patrick J. O’Connor Abstract A major factor that contributes to th…

463. 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

464. P12: Using a Televideo-based Training Model for Providers to Expand Treatment for Opioid Use Disorder in Rural New Mexico | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/profile-p12-salvador.html
     May 01, 2024 - Investments in Primary Care Research for 2021 and 2022 P12: Using a Televideo-based Training Model for Providers to Expand Treatment for Opioid Use Disorder in Rural New Mexico Previous Page Next Page Table of Contents Investments in Primary Care Research for 2021 and 2022 Acknowledgments and Auth…

465. Speaking Plainly: Communicating the Patient’s Role in Health Care Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Miranda.pdf
     July 01, 2004 - patient behavior can affect.11, 12 The second step highlights behaviors patients can use to decrease medication … errors and improve patient-provider communication regarding, for example, nonprescription drugs and

466. Final Progress Report: Patient Safety: Physician Assistant Responsibilities and Opportunities (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/crane-report.pdf
     January 01, 2024 - Final Progress Report: Patient Safety: Physician Assistant Responsibilities and Opportunities Final Report Patient Safety: Physician Assistant Responsibilities and Opportunities An educational conference program of the American Academy of Physician Assistants This program was funded by a grant from the Agency fo…

467. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - (Yount) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast4-yount.pdf
     June 02, 2025 - New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - (Yount) Introducing the AHRQ SOPS Health IT Patient Safety Supplemental Items Naomi Yount, PhD Westat Health IT Patient Safety Supplemental Items • Supplemental item set that can be added to the end of the Hospit…

468. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-West_102.pdf
     March 31, 2008 - Increase in U.S. medication-error deaths between 1983 and 1993. Lancet 1998; 351:643-644. 16.

469. 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

470. Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
     January 01, 2024 - Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians 1. TITLE PAGE Title: Developing and Training Interruption Management Strategies for Emergency Physicians Principal Investigator: Raj M. Ratwani, PhD Co-investigators: Zach Hettinger, MD, MS; Allan Fong, MS; T…

471. 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

472. 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.

473. 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…

474. 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…

475. 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…

476. 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

477. 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.

478. 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 …

479. 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…

480. 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…