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21. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/diagnostic-safety/tools/index.html
    March 01, 2024 - primary care offices consistently show that the process for managing tests is a significant source of error … a checklist and other resources to help patients understand what they can to do prevent diagnostic error … Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error

22. Mod01-Grand-Rounds-Slides (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - 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 most … An explicit statement that an error occurred. 2. … ■ Being shamed or blamed for the error. ■ Revealing poor skills/abilities. … Slide 23 Say: Eliminating human error is a futile goal, as it is not a realistic approach.

23. PowerPoint Presentation
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - 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 most … Being shamed or blamed for the error. Revealing poor skills/abilities. … Distinguishes between human error (console), at-risk behavior (coach), reckless behavior (punish). … Human error cannot be eliminated. Futile goal. Misdirects resources/focus.

24. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
    March 01, 2024 - Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating … 23 percent of patients treated at 29 academic medical centers in the U.S. experienced a diagnostic error … by Agency-funded research teams that have published essential insights into areas such as diagnostic error

25. Working Together to Tackle Our Most Pressing Safety Issues | Agency for Healthcare Research and Quality
    pcmh.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

26. Facilitator Notes | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
    December 01, 2012 - Managing Error and Risk Slide 8. Systems and Behaviors Work Together To Improve Outcomes Slide 9. … Can you identify examples of human error in your unit or hospital? … Managing Error and Risk   Say: To improve outcomes, human error, at-risk behavior, and reckless … Human error is a product of both system design and behavioral choices. … Describe the connections between communication and medical error.

27. Agency for Healthcare Research and Quality | Agency for Healthcare Research and Quality
    pcmh.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

28. Medical Errors and Patient Safety | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/research/findings/factsheets/errors-safety/index.html
    January 01, 2023 - SHARE: More topics in this section Research Publications & Products Research Findings & Reports Grantee Final Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets Medical Errors and Patient Safety Minor…

29. AHRQ Research Summit on Improving Diagnosis in Health Care | Agency for Healthcare Research and Quality
    pcmh.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

30. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/funding/grantee-profiles/grtprofile-walsh.html
    October 01, 2023 - Walsh received a 3-year AHRQ grant in 2015 to identify the factors that contribute to medication error

31. Diagnostic Safety Grants Awarded in FY 2019 | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/diagnostic-safety/research/grants-2019.html
    March 01, 2024 - machine learning models that can be used to retrospectively identify patients in whom a diagnostic error

32. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/funding/grantee-profiles/grtprofile-bell.html
    March 01, 2022 - “AHRQ is helping to pioneer a novel 360-degree approach to diagnostic error prevention by bringing patients … process so there’s a corrective mechanism that’s possible before it leads to duplication, diagnostic error … Among patients who reported a diagnostic error, the most common contributing factor patients reported … AHRQ’s vision to take such a pioneering stance on tackling the complex issue of ambulatory diagnostic error

33. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
    pcmh.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

34. Final report: To Quantify the Impact of the Existing vs. Enhanced Work Configuration of Radiation Therapy Technicians on Workload, Situation Awareness, and Performance during Pretreatment QA Tasks (pdf file)
    pcmh.ahrq.gov/sites/default/files/2024-01/mosaly-report.pdf
    January 01, 2024 - Table 1: Description of simulated scenarios and corresponding embedded error in each scenario Scenario … Description Embedded Error 1. … The error detection and procedural compliance was calculated as the average score of error detection … and/or missing information, 1 denotes proper documentation of error and/or missing information). … An alpha of 0.05 was used for an acceptable type-I error for statistical significance.

35. Issue Brief 7. Improving Education: A Key to Better Diagnostic Outcomes (pdf file)
    pcmh.ahrq.gov/sites/default/files/publications2/files/dxsafety-issuebrief-education.pdf
    March 11, 2022 - Diagnostic error in internal medicine. … Cognitive interventions to reduce diagnostic error: a narrative review. … Overconfidence as a cause of diagnostic error in medicine. … Clinical reasoning and diagnostic error: a call to merge two worlds. … Nurses, diagnosis, and diagnostic error.

36. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
    July 05, 2023 - Thus, capitation and payer integration lie to the left of direct error penalties in . … What is Diagnostic Error?: Improvediagnosis.org. diagnostic-error/ [Accessed 26 Jul 2022]. 6. … Payment innovations to improve diagnostic accuracy and reduce diagnostic error. … Interventions targeted at reducing diagnostic error: systematic review. … Diagnostic error inmedicine: analysis of 583 physician-reported errors.

37. Facapplycusp (doc file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
    September 04, 2012 - · Can you identify examples of human error in your unit or hospital? … Slide 6 SAY: To improve outcomes, human error, at-risk behavior, and reckless behavior each 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

38. Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/patient-safety/settings/ambulatory/diagnostic-safety/toolkit.html
    November 01, 2018 - SHARE: More topics in this section Patient Safety Patient Safety Research Summaries Patient Safety Resources by Setting Hospital Hospital Labor and Delivery Units Emergency Department Long Term Care Ambulatory Care Too…

39. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
    pcmh.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.

40. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    pcmh.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?