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121. 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: _______________________________

122. 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

123. 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.

124. 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.

125. 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

126. Final Progress Report: Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma (REDEFINE Study) (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/joo-report.pdf
     January 01, 2025 - Final Progress Report: Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma (REDEFINE … Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma (REDEFINE Study) Principal Investigator … Key Words Chronic Obstructive Pulmonary Disease (COPD), Asthma, Diagnostic Error (DE), Spirometry 3. … PURPOSE Aim 1: Determine the prevalence of and characteristics associated with diagnostic error (DE) … Reducing Diagnostic Error to Improve Patient Safety in COPD and Asthma (REDEFINE Study) 2.

127. 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?

128. 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

129. 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

130. 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.

131. Breakout Session: Use of Data and Measurement in Improving Diagnostic Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/brady-summit2016-breakout.pdf
     September 28, 2016 - www.ahrq.gov/news/newsroom/press- releases/2015/saving-lives.html What Makes Addressing Diagnostic Error … • Who owns the Dx error problem? … NAM (formerly IOM) Definition of Diagnostic Error The failure to: (a) establish an accurate and timely … Measuring Diagnostic Error • Research projects • Medical liability claims • Patient safety and quality … NAM (formerly IOM) �Definition of Diagnostic Error Recommendations from �the Improving Diagnosis in

132. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/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.

133. Learning From Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-1.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 … Despite growing awareness of diagnostic error, most healthcare systems do not track or record diagnostic

134. 2018 National Healthcare Quality and Disparities Report: Appendix A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa2.pdf
     January 01, 2018 - , 2014, 2016, or 2017 Person-Centered Care Improving Average Annual Percent Change Standard Error … -1.1 0.0 0.02 HHCAHPS 6 (2012- 2017) Not Changing Average Annual Percent Change Standard Error … forms -0.7 0.0 0.00 MEPS 6 (2011- 2016) Worsening Average Annual Percent Change Standard Error … -1.52 0.0 0.00 HHCAHPS 6 (2012- 2017) Not Changing Average Annual Percent Change Standard Error … Healthcare Quality and Disparities Report Not Changing Average Annual Percent Change Standard Error

135. Just Culture Webcast Intro (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-1-intro.pdf
     November 09, 2016 - Feedback & communication about error – 3. Frequency of event reporting – 4. … Nonpunitive response to error – 7. Organizational learning--continuous improvement – 8. … Nonpunitive Response to Error Survey Items – Staff feel like their mistakes are held against them. … Lowest Performing Composite Results –2016 AHRQ Comparative Database Defining Nonpunitive Response to Error … Nonpunitive Response to Error Survey Items

136. Issue Brief 26: Exploration of Foundational Terminology and Paradigms for Improving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-terminology.pdf
     April 01, 2025 - Unlike some error-focused terms, such as “diagnostic error,” that emphasize shortcomings, diagnostic … • How were judgments of “error” and preventability determined? … Diagnostic Error The 2015 National Academy report sought a consensus definition for diagnostic error … Descriptions of various categories of diagnostic error follow. … The concept of “error without harm” or an error rescued before harm impacts a specific patient is referred

137. Final Progress Report: Addressing Preventable Medication Use Variance in Mississippi (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/brown-report.pdf
     January 01, 2024 - "Evaluating the System of Medication Error in an In-Patient Setting." … "Data Warehousing Technologies to Understand Medication Error Processes." … "Use of Data Warehousing Technologies to Understand Medication Error Processes." … "Use of Data Warehousing Technologies to Understand Medication Error Processes." … “Use of data mining techniques in analyzing medication error data.”

138. Final Progress Report: Improve Safety, Quality, and Efficiency in Radiotherapy with Automated HIT System (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/yang-report.pdf
     January 01, 2024 - software tools were developed for detecting simple errors and inconsistencies based on pre-defined error … Novel error detection algorithms, including multiple machine learning-based algorithms, were developed … to detect advanced errors that are not supported by rule-based error detection. … Two methods (Median absolute deviation, Error-leveling) were developed to generate error statistical … In comparison, human workers might not be well suited for the repetitive error detection tasks.

139. News Media and Health Care Providers at the Crossroads of Medical Adverse Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
     June 05, 2008 - from the medical error equation.6, 7, 8 Although past efforts to address this important issue are … of execution) or the original intended action was not correct (e.g., an error of planning). … This latter example is most closely aligned with the lay notion of medical error. … Media mistakes in coverage of the Institute of Medicine’s error report. … Indiana medical error reporting system: Final report for 2006.

140. Final Progress Report: Risk Models To Improve Long-Term Care Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
     January 01, 2024 - in the read prevents the initiating error from being caught. … Review and Comparison with Published Literature: Medication error studies were analyzed by type of error … This type of human error typically occurs during routine tasks. … Summary of Potential for Harm by Stage and Medication Error Category Error Category Prescribing Dispensing … Medication Error Frequency by Stage and Medication Error Category Category Prescribing/Ordering Dispensing