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21. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
    August 01, 2022 - occurring in 5 percent of ED visits translates to about 7 million cases of ED-based diagnostic error … What interventions could reduce diagnostic error in emergency departments? … inform diagnosis and error. … Interdisciplinary communication: an uncharted source of medical error? … Diagnostic error in medicine: analysis of 583 physician-reported errors.

22. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.html
    August 01, 2022 - Slide 9 Say: To improve outcomes, human error, at-risk behavior, and reckless behavior should … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console providers who have committed a human error and to ensure … Forcing functions, checks, and redundancies are some features of systems intended to minimize the risk of error

23. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
    April 02, 2020 - Reducing Diagnostic Error: Measurement Considerations. … The challenges in defining and measuring diagnostic error. … The incidence of diagnostic error in medicine. … Minimizing diagnostic error: the importance of follow-up and feedback. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

24. Working Together to Tackle Our Most Pressing Safety Issues | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/news/blog/ahrqviews/patient-safety-stakeholders.html
    March 01, 2021 - Participants agreed that a third specific research priority is diagnostic error. … Diagnostic error harms too many and costs too much .   … require dedicated effort and investments in order to prevent the substantial harm we know diagnostic error

25. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
    August 01, 2022 - If the focus is on the process and the system factors that facilitated the error, the process can be … adjusted to minimize human error, resulting in fewer opportunities to err again. … (Table 1) Table 1: Behavior Classification Normal Error (Human Error) At-risk Behavior Reckless … If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … questions such as "Why was there human error?

26. Agency for Healthcare Research and Quality | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/cpi/about/mission/ahrq-fy2015-conf-spending.html
    January 01, 2016 - Total Non-Feds on Travel:  0 Center for Quality Improvement and Patient Safety (CQUIPS) Diagnostic Error … and final of three annual conferences to be held as part of the large conference grant "Diagnostic Error … response to the AHRQ funding mechanism PAR09-257 and supports the AHRQ/CQUIPS program to reduce medical error

27. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care November Meeting Summary (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/topics/fed-IWG-dxsafety-Nov19mtg.pdf
    November 15, 2019 - • Grants To Enable Diagnostic Excellence (4 awarded) CDC • Literature review linking laboratory error … grants.nih.gov/grants/guide/rfa-files/RFA-HS-19-001.html https://www.ahrq.gov/patient-safety/diagnostic-error-grants

28. Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/patient-safety/settings/ambulatory/diagnostic-safety/toolkit.html
    November 01, 2018 - 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 …

29. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
    March 01, 2017 - Can you identify examples of human error in your unit or facility? … Slide 19: Managing Error and Risk 1 Say: To improve outcomes, human error, at-risk behavior, and … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console team members who have committed a human error and to ensure

30. Resources Related to Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/diagnostic-safety/resources/index.html
    March 01, 2024 - Defining diagnostic error: a scoping review to assess the impact of the national academies' report improving … You can search diagnostic error to find related studies and resources.

31. Issues With Electronic Health Records Contribute to Diagnostic Errors | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/news/newsletters/e-newsletter/863.html
    May 01, 2023 - 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 …

32. Speaking Plainly: Communicating the Patient’s Role in Health Care Safety (pdf file)
    patientregistry.ahrq.gov/downloads/pub/advances/vol4/Miranda.pdf
    July 01, 2004 - The groups were used to identify persuasive error prevention messages and to identify the types of patient-provider … Beneficiaries also reported the assumption that the health care system takes certain error-checking … beneficiaries in focus groups generally believed the phrase “patient safety” could be used to signify medical error … Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel

33. AHRQ Research Summit on Improving Diagnosis in Health Care | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety.html
    April 01, 2019 - Quality 5600 Fishers Lane Rockville, MD 20857 Most patients will experience at least one diagnostic error … chapters, aligning with the breakout sessions: Data and Measurement— Chapter 3: Overview of Diagnostic Error

34. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
    January 01, 2019 - Feedback and Communication About Error .............................................................. … Feedback and Communication About Error 1. … Missed nursing care is a subset of the category known as error of omission. … Nonpunitive Response to Error 1. … Feedback and Communication About Error Composite 6. Communication Openness Composite 7.

35. Facilitator’s Implementation Roadmap: TeamSTEPPS® Diagnosis Improvement (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-improvement/dxsafety-facilitator-roadmap.pdf
    February 01, 2022 - Use the Course Infographic to provide current information pertaining to diagnostic error and its impact … Sharing data on the frequency of diagnostic error in both ambulatory and acute care settings and their

36. AHRQ’s Measure Dx Tool: Discover and Learn From Diagnostic Errors | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/news/newsletters/e-newsletter/831.html
    September 01, 2022 - 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 …

37. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-110620.pdf
    March 11, 2021 - and Safety of Diagnosis and o Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … • Diagnostic Error in Medicine (DEM) Conference: A presentation based on the AHRQ measurement issue

38. AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors in E.D. Patients | Agency for Healthcare Research and Quality
    patientregistry.ahrq.gov/news/newsroom/case-studies/201509.html
    January 01, 2018 - The Institute of Medicine has identified medication errors as the most common type of error in health … The pharmacist is best trained to recognize this form of error," Dr. Hays noted.

39. Understanding SOPS® Surveys: A Primer for New Users - Gray (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops-101-webcast-overview-surveys.pdf
    January 01, 2022 - Center 2015 14 Areas of Patient Safety Culture Assessed Across SOPS Surveys • Communication About Error … Openness • Organizational Learning—Continuous improvement • Overall Rating on Patient Safety • Response to Error

40. Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary (pdf file)
    patientregistry.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
    March 08, 2019 - www.cdc.gov/hai/prevent/cauti/index.html 3 AHRQ • In 2015, AHRQ issued two dedicated diagnostic error