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121. 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.

122. 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

123. 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.”

124. 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

125. 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

126. 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

127. 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

128. 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

129. Chart Review* Submission for Baseline, 12, & 18 Months (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/submission-form-mw.pdf
     June 02, 2025 - Review – Numerator on Review – Medication List Blood Pressure Status/Intervention Documentation Error … Documentation Error Documentation Error Exception on Review – Allergy Documentation List Error … Exception on Review – Diagnosis Documentation Error No Diagnosis on Review – Diagnosis Documentation … Error Not Done Patient Reason Remaining Potential Quality Gaps: _______________________________

130. Just Culture Webcast Closing (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-3-closing.pdf
     June 01, 2017 - Just Culture Webcast Closing Updating the Hospital Survey and Nonpunitive Response to Error • HSOPS … and a pilot study – Version 2.0 to be released in early 2018 – Revising the Nonpunitive Response to Error … composite to reflect Just Culture concepts 31 Nonpunitive Response to Error Response to Error … quality-patient-safety/patientsafetyculture/index.html Updating the Hospital Survey and NonpunitiveResponse to Error

131. Diagnostic Safety Research Priorities and Opportunities | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-4.html
     August 01, 2023 - NAM report Improving Diagnosis in Healthcare highlighted the critical deficiencies in diagnostic error … The report identified four broad priority research topics related to diagnostic error 60 : Patient … children’s conditions compared with their own. 39 Partnership with parents in preventing diagnostic error

132. Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/diagnostic-safety-transitions-care.pdf
     June 01, 2023 - to Diagnostic Error and Uncertainty Receiver-specific issues may also influence diagnostic error and … The study did not explicitly look at medical error. … review and adjudication process to categorize diagnostic error. … Each unique context carries its own risks for diagnostic error. … Defining, identifying, and measuring error in emergency medicine.

133. Final Progress Report: Mining complex clinical data for patient safety research (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/hripcsak-report.pdf
     January 01, 2024 - NLP was found to complement and improve upon error detection based on coded data. … We also expected that it would often be unclear whether an error actually occurred. … The error recovery component is used if a parse of the complete sentence cannot be obtained. … , based on defined parameters collected during the error reporting process. … Dynamic adaptation to critical care medical environment: error recovery as cognitive activity.

134. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-introduction.pptx
     January 12, 2022 - You might wonder, how often does diagnostic error happen? … Diagnostic error is a patient safety issue. … By error type: Missed – No diagnosis is ever reached. … Even highly skilled, motivated professionals are vulnerable to error. … What Is Diagnostic Error?

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

136. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
     February 01, 2025 - 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 … academic center for diagnostic excellence whose focus is to eliminate patient harms from diagnostic error … activities, including: Clinical programs to eliminate stroke misdiagnosis, New methods of diagnostic error … Evaluate the structure, process, and outcome effects of human-centered solutions on diagnostic error

137. Action Planning for the SOPS Surveys-Results (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-yount-sops-action-planning-tool.pdf
     June 01, 2019 - Events Reported 65 Communication Openness 64 Teamwork Across Units 62 Feedback & Communication About Error … 62 Staffing 50 Nonpunitive Response to Error 41 Handoffs & Transitions 37 33 34 Comparing to the … 62 69 69 Staffing 50 53 55 Nonpunitive Response to Error 41 47 50 Handoffs & Transitions 37 48 49 … 62 69 69 66 Staffing 50 53 55 56 Nonpunitive Response to Error 41 47 50 30 Handoffs & Transitions 37 … 62 69 69 66 Staffing 50 53 55 56 Nonpunitive Response to Error 41 47 50 30 Handoffs & Transitions 37

138. Impoving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/Improving_diagnosis_flyer.pdf
     April 01, 2019 - Impoving Diagnosis Improving Diagnosis Diagnostic error is a significant and under-recognized threat … ■ Most patients will experience at least one diagnostic error in their lifetime, according to the AHRQ … s knowledge of diagnostic safety and to develop practical tools and resources to reduce diagnostic error … can be found by visiting AHRQ’s PSNet website: https://psnet.ahrq.gov/ and searching for diagnostic error … grants.nih.gov/grants/guide/rfa-files/RFA-HS-19-003.html Tools AHRQ’s tools to reduce diagnostic error

139. Final Progress Report: Effects of Extended Work Hours on ICU Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/czeisler-report.pdf
     January 01, 2024 - The definitions used to classify incidents are provided in the following table: Medical Error Any error … in the delivery of medical care, whether harmful or trivial Serious Medical Error A medical error … Serious Error A serious medical error that is not intercepted but does not cause detectable harm, … Error A serious medical error related to the ordering or administration of pharmaceuticals, blood … error, or error with little potential for harm.

140. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
     www.ahrq.gov/downloads/pub/advances/vol2/Schiff.pdf
     January 01, 2005 - What is the probability that the error resulted in the adverse outcome? … How preventable was the error? … Error in medicine. JAMA 1994;272:1851–7. 45. Reason J. Human error. … Massachusetts Coalition for the Prevention of Medical Error. … Change ideas for preventing and minimizing diagnostic error Figure 1.