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1. Acute Care Learning Laboratory—Reducing Threats to Diagnostic Fidelity in Critical Illness | Agency for Healthcare Research and Quality
   teamstepps.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

2. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
   teamstepps.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

3. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
   teamstepps.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

4. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
   teamstepps.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

5. Applying Human Factors to Make it Easier for Clinicians to Do Their Jobs | Agency for Healthcare Research and Quality
   teamstepps.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

6. Improving the Safety of Diagnosis and Therapy in the Inpatient Setting | Agency for Healthcare Research and Quality
   teamstepps.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

7. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
   teamstepps.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

8. AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors | Agency for Healthcare Research and Quality
   teamstepps.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

9. 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)
   teamstepps.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.

10. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    teamstepps.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

11. Medical Errors and Patient Safety | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/research/findings/factsheets/errors-safety/index.html
    January 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 …

12. Preventing Medication Errors Among Children With Chronic Conditions in Outpatient and Home Settings | Agency for Healthcare Research and Quality
    teamstepps.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

13. TeamSTEPPS Diagnosis Improvement Course | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/teamstepps-program/diagnosis-improvement/index.html
    February 01, 2024 - Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error … Helen Haskell, M.A., Mothers Against Medical Error.

14. Tool: Cross-Monitoring | Agency for Healthcare Research and Quality
    teamstepps.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
    June 01, 2023 - Cross-monitoring is a harm and error reduction strategy that involves: Monitoring actions of other … Instead, it is a way to provide a safety net or an error prevention or error interruption mechanism for

15. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    teamstepps.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

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

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

18. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
    teamstepps.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.

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

20. Agency for Healthcare Research and Quality | Agency for Healthcare Research and Quality
    teamstepps.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