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talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
April 27, 2022 - Three studies
operationalized error using existing definitions only. … in published peer-reviewed
diagnostic error research?” … error work is to improve
the care of patients.” … Clinician survey on
diagnostic error
Clinician survey on
diagnostic error
Accuracy
Timeliness … Patients’ perspectives of diagnostic
error: a qualitative study.
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talkingquality.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
January 01, 2021 - machine learning models that can be used to retrospectively identify patients in whom a diagnostic error … https://www.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
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talkingquality.ahrq.gov/patient-safety/resources/learning-lab/acute-care-threats-long-desc.html
February 01, 2024 - 11/30/22
Description: The overall goal of this learning lab was to reduce the rate of diagnostic error … Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular … Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders … What contributes to diagnostic error or delay? … Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders
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talkingquality.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
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talkingquality.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
January 01, 2024 - A
person who believed she or he knew of a medical error or near miss could report the error to the … • Likelihood that error could lead to significant patient harm
• Likelihood that error resulted … This concept developed as a result of analysis of error reports during the
project. … Ameliorating an event after an initial error requires an opportunity to
catch the error by systems, … occurred and, if so, the nature of the error.
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talkingquality.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.
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talkingquality.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
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talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072320.pdf
November 06, 2020 - PSNet: Published a primer on 7/22/20 called COVID-19 and Dx
Error. … grant=R01+HS27614-01
https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error … https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
https://www.cdc.gov … Recently Published Diagnostic Safety Relevant Papers:
o Reducing the Risk of Diagnostic Error in the … www.journalofhospitalmedicine.com/jhospmed/article/222266/hospital-medicine/reducing-risk-diagnostic-error-covid
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talkingquality.ahrq.gov/diagnostic-safety/research/grants-2022.html
March 01, 2024 - to create a taxonomy to classify the contribution of electronic health records (EHRs) to diagnostic error … Use data gathered from error reporting to facilitate implementation of a multiparameter strategy that … DECODE: Diagnostic Excellence Center on Diagnostic Error
Principal Investigators:
Ramin Khorasani … Evaluate the structure, process, and outcome effects of human-centered solutions on diagnostic error … Develop site-level and groupwide benchmarking reports of error rates, diagnostic processes, and diagnostic
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talkingquality.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.
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talkingquality.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.
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talkingquality.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
June 01, 2023 - to create a taxonomy to classify the contribution of electronic health records (EHRs) to diagnostic error … Use data gathered from error reporting to facilitate implementation of a multiparameter strategy that … DECODE: Diagnostic Excellence Center on Diagnostic Error
Principal Investigators:
Ramin Khorasani … Evaluate the structure, process, and outcome effects of human-centered solutions on diagnostic error … Develop site-level and groupwide benchmarking reports of error rates, diagnostic processes, and diagnostic
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talkingquality.ahrq.gov/funding/grantee-profiles/grtprofile-miller.html
August 01, 2022 - health information technology, and other factors that can increase a woman’s risk of a CVD diagnostic error … The potential for a CVD diagnostic error can begin as soon as women describe their symptoms, according … team is studying the role of the ambulatory care environment in elevating the risk of a CVD diagnostic error … that clinicians use to help them predict CVD risk itself can be a contributing factor to diagnostic error … a human factors engineering approach cannot identify an overall formula for reducing CVD diagnostic error
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talkingquality.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
February 01, 2024 - Problem analysis using systems engineering methods to analyze the problem of diagnostic and therapeutic error … reassessing the diagnosis of patients (i.e., inside or outside their hospital rooms) when risk for diagnostic error … A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis … Identifying and assessing diagnostic error in acute care: is the electronic health record telling us … A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis
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talkingquality.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
October 01, 2021 - The initial diagnosis, while not correct, was not necessarily due to an error. … Talking about error can lead to perceptions that inadvertently suggest blame, but it’s important to remember … An example of a common type of cognitive error that can lead to a diagnostic error is called recency … Oftentimes a diagnostic error is the result of a combination of cognitive and systemic issues. … quickly to keep up with patient care when the ED is short-staffed might be more apt to make a thinking error
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talkingquality.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
August 01, 2022 - many Americans have experienced the health-related consequences and anxieties that follow a diagnostic error … One in 20 adults annually experiences a diagnostic error in outpatient settings. … These centers will develop expertise in at least one of four areas: error detection and prevention, resilience
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talkingquality.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.
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talkingquality.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.
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talkingquality.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
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talkingquality.ahrq.gov/research/findings/factsheets/errors-safety/index.html
January 01, 2023 - Skip to main content
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