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1. Error Disclosure Training and Organizational Culture | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/etchegaray.html
   August 01, 2017 - vs. 41 percent), serious error disclosure (79 percent vs. 58 percent), trust-based error disclosure … , minor error (i.e., error that causes harm that is neither permanent nor life-threatening) disclosure … disclose this error. … The improvements in minor error disclosure culture and serious error disclosure culture observed between … Minor Error Disclosure Serious Error Disclosure Error Disclosure Trust Safety Culture Teamwork

2. Table 6: Categories of Medication Error Classification | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/table-6.html
   August 01, 2012 - Hospital Hospital Resources MATCH Toolkit Table 6: Categories of Medication Error … Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Table 6: Categories of Medication Error … Appendix: The MATCH Work Plan Category Description Example A No error … , capacity to cause error NA B Error that did not reach the patient NA C Error that … harm (omissions considered to reach patient) Multivitamin was not ordered on admission D Error

3. Diagnostic error in mental health: a review (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-mental-health-bmjqs.pdf
   April 15, 2024 - Diagnostic error in mental health: a review Diagnostic error in mental health: a review Andrea Bradford … In: Committee on Diagnostic Error in Health Care. … Medical error. In: Sadock BJ, Sadock VA, Ruiz P, eds. … The challenges in defining and measuring diagnostic error. … Interventions targeted at reducing diagnostic error: systematic review.

4. Final Progress Report: Pediatric Medication Safety: Analyses from the MEDMARX Medication Error Reporting System (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/bundy-report.pdf
   January 01, 2024 - as information on the facility in which the error occurred. … Measures: The key measure of error harmfulness is known as ‘error category’ in the MEDMARX taxonomy … designation (A–I) depending on the severity of the error. … error occurred (i.e., “near misses”). … errors are common error nodes.

5. The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
   September 01, 2021 - Mortality During and Immediately After Childbirth: State of the Science The Contribution of Diagnostic Error … Immediately After Childbirth: State of the Science Introduction The Contribution of Diagnostic Error … Measurement and learning from diagnostic error (and circumstances without diagnostic error) must include … Using the Safer Dx Framework 16 as a Model for Improvement of Diagnostic Error and Contributions to … Page originally created September 2021 Internet Citation: The Contribution of Diagnostic Error

6. Medication Error Reporting Systems: Challenges, Lessons, Future Direction (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/cousins-report.pdf
   January 01, 2024 - Medication Error Reporting Systems: Challenges, Lessons, Future Direction A Report to the Agency for … Healthcare Research and Quality Project Title: Medication Error Reporting Systems: Challenges … When an error occurs, we want to know who, what, where, when, and why. … I hoped to learn more about med error reporting and interact with others focused on using error-reporting … reports, error reduction, and patient safety.

7. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
   April 27, 2022 - Three studies operationalized error using existing definitions only. … in published peer-reviewed diagnostic error research?” … error work is to improve the care of patients.” … Clinician survey on diagnostic error Clinician survey on diagnostic error Accuracy Timeliness … Patients’ perspectives of diagnostic error: a qualitative study.

8. Appendix A. Search Terms | Agency for Healthcare Research and Quality
   ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state-apa.html
   January 01, 2024 - safety/error + defining diagnostic error diagnostic safety/error + reporting diagnostic error diagnostic … safety/error + cognitive process diagnostic safety/error + cognitive biases diagnostic safety/error … safety/error + telehealth diagnostic safety/error + telemedicine diagnostic safety/error + decision … safety/error + close the loop diagnostic safety/error + interventions diagnostic safety/error + … /error + implementation diagnostic safety/error + organizational approaches diagnostic safety/error

9. Development of a Comprehensive Medical Error Ontology (pdf file)
   ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
   June 16, 2008 - Development of a Comprehensive Medical Error Ontology Development of a Comprehensive Medical Error … We believe that the ontology would also be useful in error reporting systems and medical error and near-miss … Validate medical error ontology. … Error location. 5. Contributing factors. 6. Professional activity. 7. Time of error. 8. … For example, “Documentation Error” (NIC) was added as a subconcept of “Process Error” (PTFP).

10. Grants to Enable Diagnostic Excellence | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
    January 01, 2021 - machine learning models that can be used to retrospectively identify patients in whom a diagnostic error … https://www.ahrq.gov/patient-safety/diagnostic-error-grants/index.html  

11. Research Agenda | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-4.html
    September 01, 2021 - Recognition and Prevention Factors Contributing to Diagnostic Error There is limited understanding … of contribution of diagnostic error to diagnosis or escalation of care. … Determine incidence of diagnostic error in [maternal hemorrhage] recognition. 12 Identification of … diagnosis. 19 System errors are major contributing factors to diagnostic error. … Treatment Standardizing treatment can reduce cognitive error.

12. Error Producing Conditions in the Intensive Care Unit (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
    February 26, 2008 - Error Producing Conditions in the Intensive Care Unit Error Producing Conditions in the Intensive … factors that contribute to error. … factors that contribute to error in the context of health care. … Human Error Assessment and Reduction Technique. … have the potential to reduce the risk of human error.

13. Acute Care Learning Laboratory—Reducing Threats to Diagnostic Fidelity in Critical Illness | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/resources/learning-lab/acute-care-threats-long-desc.html
    February 01, 2024 - 11/30/22 Description: The overall goal of this learning lab was to reduce the rate of diagnostic error … Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular … Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders … What contributes to diagnostic error or delay? … Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders

14. Hand Hygiene Observational Audit Tracking Tool (xls file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
    December 01, 2021 - :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR

15. The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Phillips.pdf
    January 01, 2004 - The main outcome measures were error category, error rate, and error consequence. … Distribution of error types from three AAFP error-report studies Error types AAFP 1st study (n = … 330) % error reports International (n = 429) % error reports AAFP 2nd study* (n = 838) % error … an investigation error code and a communication error code). … Distribution of error types from three AAFP error-report studies Table 2.

16. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
    March 01, 2004 - in the MEDMARX system, including medication use process node, type of error, cause of error, and contributing … ,” “error result on patient care,” and “medical devices involved in the error.” … Council for Medication Error Reporting and Prevention error categories. … by “omission error.” … taken related to the error.

17. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
    April 04, 2008 - We present a concept for a visual error reporting interface. … Error Taxonomies Error Taxonomies A number of error taxonomies have been and are being developed to … organize and classify error reports. … In this case, the error is that the primary doctor (who is reporting this error) refilled the wrong … route Wrong # of doses Wrong #of refills StorySeverity Click on this error Click where the error

18. Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
    January 01, 2004 - Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? … 371 Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? … The frank admission of a harm-causing error—e.g., “Mrs. … truthful disclosure of harm-causing error. … Error Disclosure and Malpractice Insurance 377 Should Mr.

19. 45-Iscr-Pathway-Audit-Tool (xls file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/45-iscr-pathway-audit-tool.xlsx
    June 01, 2023 - Advance care planning completed 0 0 ERROR:#DIV/0! … Carbohydrate drink consumed 0 0 ERROR:#DIV/0! … Wound protector used 0 0 ERROR:#DIV/0! Tranexamic acid administered 0 0 ERROR:#DIV/0! … Patient up in the chair 0 0 ERROR:#DIV/0! … Regular diet POD 0 or POD 1 0 0 ERROR:#DIV/0! Early mobilization 0 0 ERROR:#DIV/0!

20. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
    January 01, 2003 - First, by definition, recognition that an error has occurred means that the error happened some time … Because of this, recognition that an error has occurred is very difficult.20 Second, even if an error … again, rather than focusing on the underlying cause of the error.40 Nurses do not see error reporting … • Nurses do not recognize an error occurred. • Medication error is not clearly defined. … Medication Administration Error Reporting Survey 489 46.