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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-fullreport.pdf
November 02, 2017 - The two items in the
“Mistakes and concerns” composite—preventing mistakes by checking a patient's wristband … before giving medications and informing parents how to report potential mistakes in care—fit
together … The low item-to-
composite correlations for the “Mistakes and concerns” composite can be explained by … The composite-to-composite Pearson correlations ranged from .43
(“Mistakes and concerns”; “Preparing … • Parents were concerned about clinicians making mistakes in their child’s care.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/CUSP-Patient-Family-Engagement.pptx
May 01, 2013 - Cover slide
Explore the role of patient and family advisors
Describe how to work with patients and family advisors
Present tools to improve communication among patients, families, and clinicians
Discuss how to communicate an adverse event to a patient and family members
Learning Objectives
The Patient’s Hos…
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www.ahrq.gov/sites/default/files/2024-11/cook-report.pdf
January 01, 2024 - Final Progress Report: Probabilistic Risk Assessment Chicago Transplant Inquiry Study (PRACTIS)
FINAL REPORT
Project title: Probabilistic Risk Assessment Chicago Transplant Inquiry Study
(PRACTIS)
Principal Investigators and Team Members:
Richard Cook, MD, University of Chicago
John Wreathall, PhD, Wreathall Ass…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/ccqm-pc-mail.pdf
July 01, 2016 - Care Coordination Quality Measure for Primary Care (CCQM-PC) - Mail Materials
Care Coordination Quality Measure for
Primary Care (CCQM-PC)
Mail Materials
Cover Letter for Survey Mailing #1
{INSERT LOGO FOR PRACTICE AND/OR SURVEY VENDOR}
{FIRST AND LAST NAME}
{LINE ONE OF ADDRESS}
{LINE TW…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/communication-slides.pptx
June 01, 2021 - PowerPoint Presentation
Improving Teamwork and Communication
Long-Term Care
AHRQ Safety Program for Improving Antibiotic Use
AHRQ Pub. No. 17(21)-0029
June 2021
Improving Teamwork
1
Objectives
Recognize the importance of seeking input from all team members when making antibiotic prescribing decisions
Summarize ho…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
September 03, 2014 - People are fallible
Medicine is still treated as an art, not a science
Systems do not catch mistakes … experienced provider is influenced by the environment in which he or she works and can be responsible for mistakes … As a result, providers must increase their ability to learn from mistakes and implement procedures to … Errors also occur because systems frequently do not catch mistakes before they reach the patient.
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - A story about one's mistakes gives others permission to acknowledge their own vulnerabilities and creates
-
psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - The
error occurs when individuals fall victim to the flaws within the system and mistakes are made.
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - another study, delays in appropriate referral or consultation were the second most common phase where mistakes
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-4.html
March 01, 2022 - Engaging with second opinions and consults. 51 Fresh eyes catch mistakes, and input from experts is
-
psnet.ahrq.gov/node/33812/psn-pdf
August 01, 2016 - But we know that a lot of mistakes are out of the
control of these authorities.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustscorecard.pptx
December 01, 2017 - was shared from the perspective of sustainability, teams were instructed to focus on learning from mistakes
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www.ahrq.gov/hai/tools/mvp/modules/technical/4es-early-mobility-slides.html
February 01, 2017 - Learn from mistakes.
Early Mobility:
Update process for mobilizing patient.
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - When mistakes happen,
quality suffers, and patients suffer emotional, financial, and physical harm.(
-
psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - sustaining a culture in which health care team members communicate openly and learn from errors
and mistakes
-
psnet.ahrq.gov/node/33602/psn-pdf
March 15, 2025 - greatest impediment to error prevention
in the medical industry is that we punish people for making mistakes
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psnet.ahrq.gov/topics-0
March 03, 2025 - Active Errors Go to this topic
Cognitive Errors ("Mistakes
-
psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
August 30, 2023 - Errors in care and adverse events associated with health literacy include mistakes in diabetes management
-
digital.ahrq.gov/ahrq-funded-projects/enhancing-medication-cpoe-safety-and-quality-indications-based-prescribing
January 01, 2023 - Mistakes made by patients and providers can lead to medication errors.
-
psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
August 16, 2023 - June 1, 2015
WebM&M Cases
Diagnosing Diagnostic Mistakes