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101. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/downloads/pub/advances/vol2/pace.pdf
     January 01, 2004 - We then applied 337 of 421 available taxonomy codes to 608 error reports. … (AAFP)-Linnaeus Primary Care Patient Safety Taxonomy9 primarily applied a single global code to an error … reports to develop a hierarchical taxonomy that describes error processes in primary care. … We then analyzed all three approaches to error classification to identify those codes and constructs … National Coordinating Council for Medication Error Reporting and Prevention.

102. Developing a Taxonomy for Coding Ambulatory Medical Errors: 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/vol2/Pace.pdf
     January 01, 2004 - We then applied 337 of 421 available taxonomy codes to 608 error reports. … (AAFP)-Linnaeus Primary Care Patient Safety Taxonomy9 primarily applied a single global code to an error … reports to develop a hierarchical taxonomy that describes error processes in primary care. … We then analyzed all three approaches to error classification to identify those codes and constructs … National Coordinating Council for Medication Error Reporting and Prevention.

103. Slide 1
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability.pptx
     December 01, 2015 - ERROR:#DIV/0! ERROR:#DIV/0! May 2015 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … Jun 2015 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! Jul 2015 ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! Aug 2015 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … Sep 2015 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! Oct 2015 ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! Q2 SIR ERROR:#DIV/0!

104. Final Progress Report: Technology To Improve Medication Safety in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
     January 01, 2024 - Medication error was defined as a dose that was discrepant to the medication order. … During the analyses, medication error was considered with and without wrong-time medication error, because … had an error rate (% of medications administered in error) of 40.1%; CMT/As, 34.2%. … Table 4: Percentage of Observed Medications in Error Across Observation Periods Medication Error Type … 65% of medications observed) had an error rate of 5.6%.

105. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patient-role1.html
     September 01, 2024 - Patients and caregivers who have experienced a diagnostic error can provide a unique perspective. … goals, and concerns are too often the last to be considered. 3 , 4 The issues surrounding diagnostic error … Almost one-quarter of Americans have been affected by a diagnostic error experienced personally or by … Diagnostic process Source:  Committee on Diagnostic Error in Health Care; Board on Health Care Services … Goals for Improving Diagnosis and Reducing Diagnostic Error Source:  Committee on Diagnostic Error in

106. Final Progress Report: Accountability and Health Safety – A Statewide Approach (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/thorpe-rask-report.pdf
     January 01, 2024 - Key Words: Patient Safety, Error Reporting, Voluntary, Medication Error, Guideline Adherence, Error … The mean error reduction was 28% in 2002 and 34% in 2003. … , reported psychological reactions to medical error, and organizational policies on error disclosure … Disclosure of medical error: the need for moral courage. … Disclosing medical error: How much to tell?

107. The Timeline to Diagnostic Safety SIDM -Research as a Priority (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
     January 01, 2017 - Which is more error prone – intuition or normative approach? … What’s the Cost of Dx Error? Understanding the costs of dx error would motivate ….. … ” • Add these slides if Victor doesn’t cover them Diagnostic Error Error-related Harm 40,000 … – 80,000 deaths/yr The Toll of Dx Error Leape et al. … What’s the Cost �of Dx Error?

108. 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

109. 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.

110. 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.

111. 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?

112. 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

113. 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.

114. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
     January 01, 2024 - safety/error + burden diagnostic safety/error + measurement data and methods diagnostic safety/error … error diagnostic safety/error + reporting diagnostic error diagnostic safety/error + cognitive process … /error + electronic health record diagnostic safety/error + telehealth diagnostic safety/error + telemedicine … diagnostic safety/error + testing diagnostic safety/error + test order diagnostic safety/error + test … safety/error + resources diagnostic safety/error + communities of practice diagnostic safety/error +

115. 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.

116. 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.

117. 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

118. 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

119. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions7.html
     June 01, 2023 - Engineering, and Medicine, Institute of Medicine, Board on Health Care Services, Committee on Diagnostic Error … Defining, identifying, and measuring error in emergency medicine. … Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological … Cognitive bias impact on management of postoperative complications, medical error, and standard of care … Cognitive interventions to reduce diagnostic error: a narrative review.

120. 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