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101. 3. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
     January 01, 2024 - about a shared understanding of the definitions of certain foundational terms, such as “diagnostic error … Defining Diagnostic Error Use of a standard definition of diagnostic error across studies has remained … Graber, et al. 8 Diagnostic Error Any mistake or failure in the diagnostic process leading to … Schiff, et al. 7 Diagnostic Error Missed opportunities to make a correct or timely diagnosis … Reporting Diagnostic Error Reporting tools aid in capturing the details of diagnostic safety events

102. Final Progress Report: How Do Consumers View the Risks of Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
     January 01, 2024 - patient risk perceptions of medical errors in order to anticipate how patients will respond to medical-error … Results: Patients perceived medical-error risks based on Dreadedness and Preventability. … of the perceived risk (e.g., the degree to which that medical error is viewed as dreaded, preventable … and a second factor related to the patient's ability to prevent the error. … Promoting patient safety by preventing medical error.

103. Final Progress Report: Reducing Diagnostic Errors in Primary Care Pediatrics (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/rinke-report.pdf
     January 01, 2025 - the improvement on their second error, and maintain the improvement on their first error, with reduced … received information and training on this error. … Diagnostic difficulty and error in primary care--a systematic review. … Overconfidence as a cause of diagnostic error in medicine. … The challenges in defining and measuring diagnostic error.

104. Medication Dashboard Data 2024 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2024.xlsx
     January 01, 2024 - of Medication/Substance Event Safety Concern Frequency Percent Incorrect action (process failure or error … ) No Harm 5,413 94.1% Incorrect patient/family action (e.g., self-administration error) Harm 340 5.9% … error) Purchasing 18 0.3% Incorrect patient/family action (e.g., self-administration error) Other: … error) Monitoring 232 2.4% Incorrect patient/family action (e.g., self-administration error) Unknown … error) Environment * * Incorrect patient/family action (e.g., self-administration error) Policies and

105. Final Progress Report: Ambulatory Patient Safety of Clients in Treatment for Substance Abuse (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/mcfarland-report.pdf
     January 01, 2025 - Near Miss: An error that could have led to a Serious Event or Major Error but did not due to planned  … Suppose you commit a medical error that results in a Major Permanent Error to the patient? … Suppose you commit a medical error that results in a Major Temporary Error to the patient? … Suppose you commit a medical error that results in a Minor Permanent Error to the patient? … Suppose you commit a medical error that results in a Minor Temporary Error to the patient?

106. The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Karsh.pdf
     April 08, 2004 - learning from mistakes, staffing issues and error, technology and error, mentoring in nursing education … Number six is medical error from a systems perspective, a topic that includes error models, system … Human error, error reporting, error prevention, systems understanding, human factors engineering, and … Medical error: a discussion of the medical construction of error and suggestions for reforms of medical … education to decrease error.

107. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     www.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.

108. Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/West.pdf
     September 01, 2005 - Pace Abstract Background and objectives: Approaches to translating medical error information into … (1) develop an initial conceptual framework for depicting specific clinical processes at risk for error … In general, Learning Groups served to: • Help interpret error data. … upon the frequency of error, degree of harm associated with the error, practice culture, and anticipated … Eliminating unnecessary steps within processes can reduce error and improve efficiency.

109. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
     September 01, 2021 - Measurement and learning from diagnostic error (and circumstances without diagnostic error) must include … error to diagnosis or escalation of care. … delayed diagnosis.19 System errors are major contributing factors to diagnostic error. … Treatment Standardizing treatment can reduce cognitive error. … Using simulation to identify sources of medical diagnostic error in child physical abuse.

110. Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-3.html
     September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … most physicians do not participate in reporting mechanisms, perhaps out of unwillingness to confront error … opportunities to avoid the harsh judgment assigned to the characterization of a diagnostic safety event as an “error … The conclusion that an error happened at all might depend on the reviewer’s perspective; in fact, consensus

111. Device Dashboard Data 2025 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2025.xlsx
     January 01, 2025 - The tables include the relative frequencies by type of device, by device defect, failure or use error … Description answer Frequency Percentage Combination or interaction of device defect or failure and use error … 3.2% Device defect or failure, including HIT 16777 29.5% Unknown 32802 57.6% Use error … 130 13.6% No Harm Combination or interaction of device defect or failure and use error 826 … 504 14.5% No Harm Use error 2963 85.5% DEVICE_5 HIT Device Related to Event or Unsafe

112. Using Data Mining to Predict Errors in Chronic Disease Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-McCabe_39.pdf
     March 28, 2008 - ” or “no error.” … ” and numbers denoting “error.” … The decision tree, when tested on the synthetic data, predicts the occurrence of “error” and “no error … ” or “no error.” … ” and numbers denoting “error.”

113. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - the ICU to the general ward face numerous obstacles, placing them at significant risk for diagnostic error … focus on clinical criteria such as ICU readmissions, few focus explicitly on preventing diagnostic error … embedding diagnostic pauses, and measuring post discharge diagnostic outcomes can mitigate diagnostic error

114. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1.html
     July 01, 2023 - Hopkins University Christina Yuan Johns Hopkins University Helen Haskell Mothers Against Medical Error

115. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2.html
     July 01, 2023 - Hopkins University Christina Yuan Johns Hopkins University Helen Haskell Mothers Against Medical Error

116. Nurses' Role in Diagnosis, Through the Lens of Distributed Cognition | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses3.html
     August 01, 2022 - Areas for Future Research Conclusion References The landmark report on diagnostic error … Any shortcomings in eliciting all relevant information from a patient can contribute to diagnostic error … perspective and language use contribute to framing effects and context errors that may lead to diagnostic error

117. Research on Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/index.html
     November 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 affect … 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

118. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-presenters-notes.pdf
     January 12, 2022 - You might wonder, how often does diagnostic error happen? … Slide 5 Diagnostic error is a patient safety issue. … Slide 11 Diagnostic Error Is Common and Harmful and Affects Many Diagnostic error is common and … What Is Diagnostic Error? Types of Diagnostic Error Where Do Diagnostic Errors Occur? … Communication and the Diagnostic Process Causes of Diagnostic Error Diagnostic Error Is Common and

119. Final Progress Report: Multi-Method Proactive Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/pace-report.pdf
     January 01, 2024 - reporting systems, the Medical Group Management Association Office Procedures Survey, and an error … Key Words: ambulatory safety culture, readiness to change, error reporting, error visualization Purpose … error reporting demonstration project as well as using local error reporting data. … reports submitted to UCH's error reporting system from UCH ambulatory practices. … Error Reporting System Review The analysis of the ASIPS ambulatory error reports has been extensively

120. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Schiff (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new_sops_diagnostic_safety-schiff.pdf
     January 01, 2020 - This investment was spread across six complementary research areas: (1) health systems error reporting … Experienced by MA Residents BETSY LEHMA CENTEF for Patient Safety and Medical Error % saying … The Public’s View on Medical Error in Massachusetts, September 2–28, 2014. 21% Experienced Medical … Error IHI/NPSF 2017 Survey 21 Misdiagnosis Leading Type of Error 22 Misdiagnosis 59 Mistake … Medical Error Misdiagnosis Leading Type of Error Top Allegation Types Closed With Indemnity Paid