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41. Facilitator’s Implementation Roadmap: TeamSTEPPS® Diagnosis Improvement (pdf file)
    talkingquality.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

42. AHRQ’s Measure Dx Tool: Discover and Learn From Diagnostic Errors | Agency for Healthcare Research and Quality
    talkingquality.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 …

43. Postdiscalldoc (pdf file)
    talkingquality.ahrq.gov/sites/default/files/publications/files/postdiscalldoc.pdf
    February 14, 2013 - _______________________  Intentional nonadherence  Inadvertent nonadherence  System/provider error … _______________________  Intentional nonadherence  Inadvertent nonadherence  System/provider error … _______________________  Intentional nonadherence  Inadvertent nonadherence  System/provider error

44. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Health Care (pdf file)
    talkingquality.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

45. AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors in E.D. Patients | Agency for Healthcare Research and Quality
    talkingquality.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.

46. Understanding SOPS® Surveys: A Primer for New Users - Gray (pdf file)
    talkingquality.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

47. Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary (pdf file)
    talkingquality.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

48. Toolkit for Engaging Patients To Improve Diagnostic Safety  | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/diagnostic-safety/tools/engaging-patients-improve.html
    July 01, 2022 - Diagnostic errors occur in all care settings and one in three patients will experience a diagnostic error

49. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
    January 01, 2022 - Errors Learning Network demonstrate the value of collecting and sharing deidentified diag- nostic error … Committee on Diagnostic Error in Health Care. Improving diagnosis in health care. … Advancing the research agenda for diagnostic error reduction. … Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–1499. 4. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

50. Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance (pdf file)
    talkingquality.ahrq.gov/downloads/pub/advances/vol1/Schillinger.pdf
    January 01, 2004 - Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel

51. Meeting Minutes, November 2015 | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/events/nac/2015-11-nac/nacmtg1115-minutes.html
    May 01, 2016 - It evaluated diagnostic error as a quality-of-care challenge and examined the epidemiology, burden of … harm, economic costs of error, and efforts to address the problem. … He described diagnostic error issues, such as the fact that diagnostic error is notoriously difficult … Dedicated funding for diagnostic error projects at AHRQ has been modest during the past dozen years. … We need longitudinal data on diagnostic error, and we need to determine error rates.

52. Diagnostic Errors Are Common in Seriously Ill Hospitalized Adults | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/newsletters/e-newsletter/895.html
    January 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 …

53. TeamSTEPPS Learning Benchmarks (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/tools/ts-learning-benchmarks.pdf
    May 31, 2023 - doctor on the team make a misstatement about a sick patient, a comment that could result in a medical error … The following are human factor problems that research has identified as contributing to medical error … the right information 4 E • Two-Challenge rule • CUS (Concerned-Uncomfortable-Patient Safety) • Error … the line; resolve the confusion • Respect the input • Team dynamic • Focus on the safety, not the error … part of the team 10 B • Debrief-the word more than the concept • Deals with issues of blame and error

54. Developing Innovative Simulation-Based Training to Improve Patient Safety in Radiation Oncology | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/funding/grantee-profiles/grtprofile-mazur.html
    March 01, 2023 - While radiation therapy has relatively low error and injury rates, studies show that most errors occurring

55. Federal Interagency Workgroup on Improving Diagnostic Safety: July Meeting Summary (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-jul2023.pdf
    November 03, 2023 - Some of these will be on diagnostic error. … https://www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1 … https://www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2

56. Understanding SOPS® Surveys: A Primer for New Users - Gray (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/sops_101_webcast-2022-gray.pdf
    January 01, 2022 - available 15 Areas of Patient Safety Culture Assessed Across SOPS Surveys • Communication About Error … Organizational Learning – Continuous Improvement • Overall Rating on Patient Safety • Response to Error

57. TeamSTEPPS Learning Benchmarks | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/teamstepps/instructor/reference/learnbench.html
    March 01, 2014 - doctor on the team make a misstatement about a sick patient, a comment that could result in a medical error … The following are human factor problems that research has identified as contributing to medical error … Sharing the right information 4 E Two-Challenge rule CUS (Concerned-Patient Safety) Error … Stop the line; resolve the confusion Respect the input Team dynamic Focus on the safety, not the error … of the team 10 B Debrief-the word more than the concept Deals with issues of blame and error

58. Spanish Translation of AHRQ's Hospital Survey on Patient Safety (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital_survey_composites-spanish.pdf
    October 01, 2009 - Cuando se comete un error, pero es descubierto y corregido antes de afectar al paciente, ¿qué tan a menudo … Cuando se comete un error, pero no tiene el potencial de dañar al paciente, ¿qué tan frecuentemente es … Cuando se comete un error que pudiese dañar al paciente, pero no lo hace, ¿qué tan a menudo es reportado

59. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
    August 01, 2022 - Wu discusses this concept in his article "Medical Error: The Second-Victim" and the associated "expectation … important, even though some degree of emotional distress is likely when a clinician is involved in any error … the second-victim phenomenon even in cases where no adverse event occurred, but they feared that an error … Providers can also experience profound problems after adverse events that were not associated with medical error … During this stage, the second-victim might tell someone about the error/event as their way of asking

60. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/diagnostic-safety/workgroup/index.html
    March 01, 2024 - In Improving Diagnosis , NASEM outlined eight goals to reduce diagnostic error and improve diagnosis