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81. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality.html
    September 01, 2021 - Immediately After Childbirth: State of the Science Introduction The Contribution of Diagnostic Error … References Issue Brief 6 Contents Introduction The Contribution of Diagnostic Error

82. Breakout Session: Use of Data and Measurement in Improving Diagnostic Safety (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/brady-summit2016-breakout.pdf
    September 28, 2016 - www.ahrq.gov/news/newsroom/press- releases/2015/saving-lives.html What Makes Addressing Diagnostic Error … • Who owns the Dx error problem? … NAM (formerly IOM) Definition of Diagnostic Error The failure to: (a) establish an accurate and timely … Measuring Diagnostic Error • Research projects • Medical liability claims • Patient safety and quality … NAM (formerly IOM) �Definition of Diagnostic Error Recommendations from �the Improving Diagnosis in

83. Using Data Mining to Predict Errors in Chronic Disease Care (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-McCabe_39.pdf
    March 28, 2008 - ” or “no error.” … ” and numbers denoting “error.” … The decision tree, when tested on the synthetic data, predicts the occurrence of “error” and “no error … ” or “no error.” … ” and numbers denoting “error.”

84. Just Culture Webcast Intro (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-1-intro.pdf
    November 09, 2016 - Feedback & communication about error – 3. Frequency of event reporting – 4. … Nonpunitive response to error – 7. Organizational learning--continuous improvement – 8. … Nonpunitive Response to Error Survey Items – Staff feel like their mistakes are held against them. … Lowest Performing Composite Results –2016 AHRQ Comparative Database Defining Nonpunitive Response to Error … Nonpunitive Response to Error Survey Items

85. Grand Rounds Presentation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - and not just checking the box on their process when they do their analysis of the error. … In Rosemary Gibson's book: Responding to medical error is a part of health care where we should be … Being shamed or blamed for the error. Revealing poor skills/abilities.   … This is a cornerstone of the CANDOR process of investigating the root cause of how an error occurred, … The surgeon gave her an immediate and sensitive apology for the error, accepting full responsibility.

86. 2018 National Healthcare Quality and Disparities Report: Appendix A (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa2.pdf
    January 01, 2018 - , 2014, 2016, or 2017 Person-Centered Care Improving Average Annual Percent Change Standard Error … -1.1 0.0 0.02 HHCAHPS 6 (2012- 2017) Not Changing Average Annual Percent Change Standard Error … forms -0.7 0.0 0.00 MEPS 6 (2011- 2016) Worsening Average Annual Percent Change Standard Error … -1.52 0.0 0.00 HHCAHPS 6 (2012- 2017) Not Changing Average Annual Percent Change Standard Error … Healthcare Quality and Disparities Report Not Changing Average Annual Percent Change Standard Error

87. News Media and Health Care Providers at the Crossroads of Medical Adverse Events (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-Whitten_85.pdf
    June 05, 2008 - from the medical error equation.6, 7, 8 Although past efforts to address this important issue are … of execution) or the original intended action was not correct (e.g., an error of planning). … This latter example is most closely aligned with the lay notion of medical error. … Media mistakes in coverage of the Institute of Medicine’s error report. … Indiana medical error reporting system: Final report for 2006.

88. Device or Medical/Surgical Supply, Including HIT Dashboard | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/devices.html
    October 01, 2023 - the type of device; type of device by residual harm to the patient; device defect, failure, or user error … ; device defect, failure, or user error by residual harm to the patient; type of health information technology

89. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
    January 29, 2008 - First, we need to define medical error. … Error or delay in diagnosis 2. Failure to employ indicated tests 3. … Technical error in the performance of a procedure 6. Error in administering treatment 7. … Error in dose or method of use of a drug 8. … behavior may be related to several categories of error.

90. Improving Antibiotic Use is a Patient Safety Issue
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-slides.pptx
    November 01, 2019 - Human Error. Cambridge: Cambridge University Press; 1990. … Human Error. Cambridge: Cambridge University Press; 1990. … Human Error. Cambridge: Cambridge University Press; 1990. … Human Error. Cambridge: Cambridge University Press; 1990. … Human Error. Cambridge: Cambridge University Press; 1990.

91. Silence A Commentary | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - This is what it feels like when you lose a loved one to a medical error. … , a systems error, or both. … In some cases, it may be a provider or team that takes responsibility for the error; in other cases, … In the past, patients experienced only silence and abandonment after a medical error. … The many faces of error disclosure: A common set of elements and a definition .

92. Taxonomic Guidance for Remedial Actions (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
    December 23, 2004 - do not directly cause the error. … The human error sub-subpath (human error how/why) is based to a large extent on the SRK approach described … Human Error. Cambridge: Cambridge University Press; 1990. 2. Norman D. … “SMART” error management in a radiotherapy quality system. … Medication error prevention “toolbox.” Medication Safety Alert, June 2, 1999.

93. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schiff.pdf
    January 01, 2005 - What is the probability that the error resulted in the adverse outcome? … How preventable was the error? … Error in medicine. JAMA 1994;272:1851–7. 45. Reason J. Human error. … Massachusetts Coalition for the Prevention of Medical Error. … Change ideas for preventing and minimizing diagnostic error Figure 1.

94. Appendix B. External Experts for Qualitative Interviews | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state-apb.html
    January 01, 2024 - Diagnostic error researcher in pediatrics Kelly Smith, Ph.D. … Diagnostic error educator Andrew Auerbach, M.D. … Two decades of diagnostic error experience Mark Graber, M.D. … Two decades of diagnostic error experience Page last reviewed January 2024

95. From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
    January 01, 2004 - The Error Tool Survey, also completed by team members, assessed the kinds of errors that were actually … processes (the differential recognition of error across disciplines); behavioral aspects (perception … At times, they noted the need for more aggressive management but use of the word “error” or “mistake … Only about two-thirds of them, however, would tell the patient about this error. … An error by any other name. Am J Nurs 2004;04(6):32– 43;quiz 44. 4. Cook AF, Hoas H.

96. Research on Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/research/index.html
    March 01, 2024 - effectively measure them; successful use of health information technology (IT) to prevent diagnostic error … Studies AHRQ has funded several recent studies on diagnostic error: Outpatient diagnostic errors … A third (36%) reported no help in diagnostic error reduction from their electronic health record. … and resources can be found by visiting AHRQ's Patient Safety Network and searching for diagnostic error … following areas of interest: Two areas of focus aligned with frontline diagnostician support: Safety-I error

97. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1.html
    July 01, 2023 - Hopkins University Christina Yuan Johns Hopkins University Helen Haskell Mothers Against Medical Error … https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1

98. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2.html
    July 01, 2023 - Hopkins University Christina Yuan Johns Hopkins University Helen Haskell Mothers Against Medical Error … https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2

99. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
    May 01, 2003 - Medical error: a discussion of the medical construction of error and suggestions for reforms of medical … education to decrease error. … Medical error: the second victim. BMJ 2000;320(7237):726–7. 13. … Understanding medical error and improving patient safety in the inpatient setting. … Improving medication administration error reporting systems. Why do errors occur?

100. Slide 1 (ppt file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-100813.ppt
     January 01, 2013 - National Coordinating Council for Medication Error Reporting and Prevention A – I Error Severity Taxonomy … Blameless error, corrective training, counseling indicated Blameless error NO Culpable Gray … Feedback & Communication about Error Feedback & Communication about Error Nonpunitive Response to Error … Nonpunitive Response to Error Nonpunitive Response to Error Staffing Staffing Staffing Hospital Management … Feedback & Communication about Error Feedback & Communication about Error Nonpunitive Response to Error