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141. 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

142. 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

143. 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.

144. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
     January 01, 2002 - Organizational Climate, Stress, and Error in Primary Care: The MEMO Study 65 Organizational Climate … , Stress, and Error in Primary Care: The MEMO Study* Mark Linzer, Linda Baier Manwell, Marlon Mundt … * Occupational Stress and PReventable Error measure. … Climate, Stress, and Error in Primary Care 77 References 1. Firth-Cozens J. … Organizational culture and medication error reporting.

145. 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.

146. 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.

147. 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.

148. Transcript: Using Just Culture To Improve Hospital SOPS Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/events/webinars/just-culture/transcript.html
     January 01, 2017 - to feature Celeste Mayer, who will talk about her experiences improving the Nonpunitive Response to Error … for this webinar, Nonpunitive Response to Error. … So, what is Nonpunitive Response to Error? What does it really consist of? … to what we call Response to Error, to include more Just Culture principles in the survey items. … There is a section for Nonpunitive Response to Error.

149. 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.

150. 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

151. 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

152. 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

153. 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

154. 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.”

155. 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.

156. 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

157. TeamSTEPPS® Diagnosis Improvement: Module 1 Introduction
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-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?

158. 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?

159. Brain Based Learning Strategies to Improve TeamSTEPPS® Deployment and Health Care High Reliability | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/events/webinars/jan-2017.html
     January 01, 2017 - Error Management Theory Slide 41. Error Management Learning Paradigm Slide 42. … Error Management Theory Slide 43. Error Management Theory Slide 44. … Error Management Theory Slide 45. Error Management Theory Slide 46. … detection , and how best to manage the error, or error recovery . … Return to Contents   Slide 46 Error Management Theory A study about Error Management Theory

160. Learning From Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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