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21. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
    June 30, 2004 - Diagnostic testing error reports had more event activity codes than other types of error reports (mean … reports and other error reports. … through a combination of subordinate communication error codes. … Analysis of Medical Error Event Reports 145 8. … Data elements in ASIPS error reports Table 2.

22. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
    January 01, 2004 - The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data 195 … The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data … Abstract This paper examines the impact of an Internet-based method on the collection of medication error … Finally, the missing or unspecified data from the cause-of-error variable decreased from 18.6 percent … Several studies suggest that medical error is the third-leading cause of death in the United States,

23. Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists.html
    September 01, 2020 - Quality in Healthcare Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction. … EF Related Publications Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … 2020 Internet Citation: Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error

24. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (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-Neuspiel_43.pdf
    March 05, 2008 - Improving Error Reporting in Ambulatory Pediatrics with a Team Approach Improving Error Reporting in … Medical error reports, 2005 and 2006. … Some examples of error reports in each of these categories are listed in Table 1. … Examples of error reports in pediatric ambulatory practice Communications Error: Child with varicella … Medications Error: Wrong vaccine administered (several similar reports).

25. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety.html
    September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error. … Citation: Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error

26. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
    January 01, 2016 - Diagnostic Error Measures: For Quality Improvement & Patient Safety Research Diagnostic Error Measures … Diagnostic Error Measures Types of Patient Safety & Quality Measures xxVoluntary Reporting Chart … trigger report • PPV > 70% • Requires programming • Fully automated IOM Definition: Diagnostic Error … JAMA. 2001;285:2114-2120 Wrong-Patient Error Measures Retract-and-Reorder Tool Applied to Complete … Diagnostic Error Measures:�For Quality Improvement & �Patient Safety Research Slide Number 2 Slide

27. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
    March 11, 2005 - AHRQ WebM&M—Online Medical Error Reporting and Analysis 211 AHRQ WebM&M—Online Medical Error Reporting … Online Error Reporting and Analysis 215 Cases.” … Online Error Reporting and Analysis 217 Table 2. … Online Error Reporting and Analysis 221 6. Orlander JD, Fincke BG. … Adverse event/error types among published cases* Figure 1.

28. Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
    January 01, 2024 - ; 50%, by cause of error; and 20%, by therapeutic class of the drugs involved in an error. … We never went past the type of error. … (n = 30) Severity of error 13 Type of error 22 Phase (node) of medication use process in which error … originated 11 Cause of the error 14 Drugs involved in the error 22 Actions taken in response to … an error report to prevent error from recurring 12 Source: Outcomes survey 17 Table 3.

29. Tool 1: Readmission Data Analysis and Interpretation (xls file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
    September 20, 2016 - ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0!

30. Conclusions and Next Steps | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-5.html
    September 01, 2021 - Immediately After Childbirth: State of the Science Introduction The Contribution of Diagnostic Error … Although, many factors that contribute to diagnostic error in maternal health are unknown, there are … feasible solutions, including simulation to both determine the causes of and reduce diagnostic error … More research is needed to identify related factors that contribute to diagnostic error and to determine

31. Diy-Run-Chart-Tool (xls file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/diy-run-chart-tool.xlsx
    June 21, 2021 - :#N/A 25% Dec'12 ERROR:#N/A 25% Jan'13 ERROR:#N/A 25% Feb'13 ERROR:#N/A 25% Mar'13 ERROR: … #N/A 25% Apr'13 ERROR:#N/A 25% May'13 ERROR:#N/A 25% Jun'13 ERROR:#N/A 25% Safety Net Medical … :#N/A 0% Aug'12 ERROR:#N/A 0% Sep'12 ERROR:#N/A 0% Oct'12 ERROR:#N/A 0% Nov'12 ERROR:#N/A … 0% Dec'12 ERROR:#N/A 0% Jan'13 ERROR:#N/A 0% Feb'13 ERROR:#N/A 0% Mar'13 ERROR:#N/A 0% … Apr'13 ERROR:#N/A 0% May'13 ERROR:#N/A 0% Jun'13 ERROR:#N/A 0% Safety Net Medical Home Initiative

32. Final Progress Report: Technology To Improve Medication Safety in Nursing Homes (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
    January 01, 2024 - Medication error was defined as a dose that was discrepant to the medication order. … During the analyses, medication error was considered with and without wrong-time medication error, because … had an error rate (% of medications administered in error) of 40.1%; CMT/As, 34.2%. … Table 4: Percentage of Observed Medications in Error Across Observation Periods Medication Error Type … 65% of medications observed) had an error rate of 5.6%.

33. Inpatient-to-Outpatient Transitions | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html
    June 01, 2023 - In one study, 49 percent of patients experienced at least one medical error after discharge, related … prospective cohort study of unplanned 7-day and 30-day hospital readmissions found that diagnostic error … review and adjudication process to categorize diagnostic error. … A systematic review of cognitive interventions to reduce diagnostic error across healthcare settings … However, most interventions were not tested directly for error reduction in clinical practice.

34. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
    January 01, 2004 - to the overall error rate found in the prescription error studies. … error-reduction practices might affect error rate. … be an inefficient way to reduce error when the error rate already is quite low. … Several error-reduction practices had surprisingly low error-reduction scores. … Error reporting also receives a low score when it is treated as an error reduction practice.

35. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
    January 01, 2024 - As the lead Federal agency investing in research to improve diagnostic safety and reduce diagnostic error … MB) Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Emergency Departments  ( PDF , 3 MB) Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Defining diagnostic error: a scoping review to assess the impact of the national academies' report improving

36. Next Steps and a Call to Action | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions6.html
    June 01, 2023 - Each unique context carries its own risks for diagnostic error. … Table 1 highlights and summarizes specific strategies that can help mitigate diagnostic error at each … Care transitions, sources of error, and potential mitigating strategies Care Transition Latent … Research is needed to more explicitly study the impact of these interventions on diagnostic error and … to scale up and nationally implement effective tools to mitigate diagnostic error.

37. OR-to-ICU Transitions | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions4.html
    June 01, 2023 - This transition is prone to technical and diagnostic error due to not only the high patient acuity and … The study did not explicitly look at medical error. … It is challenging to explicitly evaluate diagnostic error as an outcome in the postoperative period: … Although medical error and information omission are common outcomes in many studies, none isolate the … effect of handoff standardization on diagnostic error in the postoperative period.

38. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
    January 01, 2024 - safety/error + burden diagnostic safety/error + measurement data and methods diagnostic safety/error … error diagnostic safety/error + reporting diagnostic error diagnostic safety/error + cognitive process … /error + electronic health record diagnostic safety/error + telehealth diagnostic safety/error + telemedicine … diagnostic safety/error + testing diagnostic safety/error + test order diagnostic safety/error + test … safety/error + resources diagnostic safety/error + communities of practice diagnostic safety/error +

39. 3. Results | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
    January 01, 2024 - about a shared understanding of the definitions of certain foundational terms, such as “diagnostic error … Defining Diagnostic Error Use of a standard definition of diagnostic error across studies has remained … Schiff, et al. 7 Diagnostic Error Missed opportunities to make a correct or timely diagnosis based … Singh, et al. 59 Diagnostic Error The failure to: (a) establish an accurate and timely explanation … Reporting Diagnostic Error Reporting tools aid in capturing the details of diagnostic safety events

40. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
    January 01, 2003 - Nursing personnel directly involved in a medical error were interviewed within 2 weeks of the error. … and at times when no error occurred. … and on the error shift differed from times when no error occurred, suggesting that transient working … error was made. … minutes prior to the error.