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  1. monahrq.ahrq.gov/research/publications/search.html
    January 01, 2024 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error
  2. monahrq.ahrq.gov/research/publications/search.html?page=1
    September 01, 2022 - Safety Issue Brief #6: This issue brief discusses what is known about the contribution of diagnostic error … Safety Issue Brief #5: Despite the enormous financial cost and patient harm resulting from diagnostic error
  3. monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/nurse-role-dxsafety.pdf
    September 02, 2022 - Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, … Nurses, diagnosis, and diagnostic error. Diagnosis. 2017;4(4):197-199. doi:10.1515/dx- 2017-0027. … Diagnostic error: safe and effective communication to prevent diagnostic errors. … • What are some reasons an error could occur related to your work environment? … • How and to whom would you report this error [or missed opportunity]?
  4. monahrq.ahrq.gov/teamstepps/about-teamstepps/leadershipbriefing.html
    April 01, 2017 - who communicate effectively and back each other up dramatically reduce the consequences of human error … Human factors research has shown that even highly skilled, motivated professionals are vulnerable to error … also shown that: Teams that communicate effectively and back each other up reduce the potential for errorError reduction and performance improvement in the emergency department through formal teamwork training … Increased pre-op deep vein thrombosis prophylaxis prior to induction from 92% to 100%. 1 Better error
  5. monahrq.ahrq.gov/funding/process/study-section/peerrev.html
    March 01, 2024 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …
  6. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
    July 12, 2018 - Annually, 1 in 20 outpatients experiences a diagnostic error 55% of patients said diagnostic errors
  7. monahrq.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.html
    August 01, 2022 - While restitution for patients and families affected by medical error is essential, the standard process … frustration and anger for patients and can diminish the opportunity for hospitals to learn and improve from error
  8. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/ancillary.pdf
    March 19, 2014 - administering the medication, and the resident’s situation awareness and cross-monitoring break an error … chain that could have resulted in a medication dosage error for this patient. … Might add in here an opportunity to mentor or communicate the error so the other team member will be … Although not life threatening, the error placed the patient at unnecessary risk, delayed his disposition … The physician calls X Ray about the error and someone from the ER must track down the original film.
  9. monahrq.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
    September 01, 2022 - Treatment (Not reviewed) (Not reviewed) Summary of Evidence ADEs: Infusion Pumps/Medication Error … Nonpharmacologic Intervention Programs (Not reviewed) (Not reviewed) Summary of Evidence Diagnostic Error
  10. monahrq.ahrq.gov/teamstepps/lep/handouts/lepevidencesum.html
    December 01, 2012 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …
  11. monahrq.ahrq.gov/patient-safety/reports/engage/medlist.html
    October 01, 2022 - Studies show that 5 to 7 percent of prescriptions result in a medication error.
  12. monahrq.ahrq.gov/sops/about/patient-safety-culture.html
    March 01, 2022 - The areas of patient safety culture assessed by the AHRQ SOPS surveys include: Communication About Error … Response to Error. Staffing. Supervisor and Management Support for Patient Safety.
  13. monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-v2-resourcelist.pdf
    April 01, 2023 - Communication About Error 1. … Response to Error 1. … Missed nursing care is a subset of the category known as error of omission. … Communication About Error 1. Communication and Optimal Resolution (CANDOR) Toolkit 2. … Response to Error 1.
  14. monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
    June 09, 2016 - Patient Safety Instructions This survey asks for your opinions about patient safety issues, medical error … · An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … years or more SECTION I: Your Comments Please feel free to write any comments about patient safety, error
  15. monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
    December 22, 2017 - Patient Safety Instructions This survey asks for your opinions about patient safety issues, medical error … • An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … or more SECTION I: Your Comments Please feel free to write any comments about patient safety, error
  16. monahrq.ahrq.gov/teamstepps/instructor/scenarios/ed.html
    March 01, 2014 - administering the medication, and the resident's situation awareness and cross-monitoring break an error … chain that could have resulted in a medication dosage error for this patient. … Although not life threatening, the error placed the patient at unnecessary risk, delayed his disposition … appropriately raises the question again, which results in the correction of a potential medication error … The physician calls X Ray about the error and someone from the ER must track down the original film.
  17. monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
    May 20, 2016 - with drug reaction ∗ Death associated with adverse drug reaction ∗ Death associated with medication error … Procedures  Prophylaxis  Resuscitation  Supervision/management  Triage/transitions  Human error … usual procedures performed in accordance with standards of care) and nosocomial infections  Human error … Multi-professional mortality review: supporting a culture of teamwork in the absence of error finding
  18. monahrq.ahrq.gov/sites/default/files/wysiwyg/topics/dagnostic-safety-workgroupmeeting-notes-july2022.pdf
    November 03, 2022 - • Diagnostic Error in Medicine (DEM) Conference o AHRQ will be presenting on the 4 resources from
  19. monahrq.ahrq.gov/questions/resources/index.html
    November 01, 2020 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …
  20. monahrq.ahrq.gov/funding/process/study-section/peerdesc.html
    July 01, 2017 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

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