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141. Final Progress Report: The Effect of EMR on Medication Safety: A SPUR-Net Study (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/kuo-report.pdf
     January 01, 2024 - error" as follows: "A medication error is any preventable event that may cause or lead to inappropriate … Medication error nodes (i.e., when the error was thought to have occurred) included prescribing, dispensing … The National Coordinating Council for Medication Error Reporting and Prevention: About Medication Error … Physician order entry system cuts error rate, improves path compliance, tracks data. … The impact of computerized physician order entry on medication error prevention.

142. Final Progress Report: Improving Patient Safety: Health Systems Reporting, Analysis and Safety Improvement Research Demonstrations (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
     January 01, 2025 - Error-related concerns varied by key patient and hospital characteristics. … Content of medical error disclosures. … The Wrong Shot: Error Disclosure. … Hospitalized Patients’ Attitudes about Participation in Error Prevention. … Aim 2: Evaluate methods for analyzing medical error and safety event data.

143. Closing Gaps in Research ~ Organizationsand Healthcare Diagnoses (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/goeschel-summit2016.pdf
     June 02, 2025 - errors and near misses in clinical practice 8 Goals to Improve Diagnosis and Reduce Diagnostic Error … Priorities for Organization Focused Research 1: How to tie NAM recommendations to existing work Dx Error … Slide Number 6 8 Goals to Improve Diagnosis and Reduce Diagnostic Error 8 Goals to Improve Diagnosis … and Reduce Diagnostic Error Three Pragmatic Challenges and Priorities for Organization Focused Research … Acrobat Accessibility Report Accessibility Report Filename: Goeschel AHRQ Dx Error

144. ED-to-Hospital Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions2.html
     June 01, 2023 - and to Diagnostic Errors and Uncertainty EDs are among the most common settings in which diagnostic error … both about the diagnostic process and these overall expectations, may yield diagnostic uncertainty, error … to Diagnostic Error and Uncertainty Receiver-specific issues may also influence diagnostic error and … Research on diagnostic uncertainty and error at the ED-hospital interface should move forward in two … Promising approaches toward this end (e.g., Symptom-Disease Pair Analysis of Diagnostic Error) 53 must

145. Linking Characteristics of High-Performing Hospitals With Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/etchegaray3-report.pdf
     January 01, 2024 - Methods: We created two new surveys – HPWS and error disclosure culture – across these five studies … predictive validity of two new measures – one to measure HPWS practices, and the other to measure error … Key Words: high-performance work systems (HPWS), error-disclosure culture, measurement equivalence, … Error disclosure: A new domain for safety culture assessment. … Error Disclosure: A New Domain for Assessing Safety Culture.

146. Diagnostic Safety Centers of Excellence Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/grants-2022.html
     August 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 … Addressing electronic health record contributions to diagnostic error. … academic center for diagnostic excellence whose focus is to eliminate patient harms from diagnostic error … Evaluate the structure, process, and outcome effects of human-centered solutions on diagnostic error

147. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - First, we need to define medical error. … Error or delay in diagnosis 2. Failure to employ indicated tests 3. … Technical error in the performance of a procedure 6. Error in administering treatment 7. … Error in dose or method of use of a drug 8. … behavior may be related to several categories of error.

148. Final Progress Report: MOVES: Patient-Based Strategy To Reduce Errors in Diabetes Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/oconnor-report.pdf
     January 01, 2024 - It also appears that a given physician makes the same error recurrently. … error is the main dependent variable of interest for Hypothesis 1. … However, it is important to recall that, among all patients with an error of commission or an error … rates, other error reduction strategies may significantly reduce error rates. … Analyses for each error included patients with specified errors pre-intervention.

149. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
     January 01, 2024 - Results Laboratory test error rates (and other metrics) significantly predicted real-world error rates … The results indicated that error rates on the tasks were positively correlated with real-world error … error rates (adjusted R2 = .12 and R2 = .18). … With the error rate (the complement of the error rate will be called the accuracy rate) of a new drug … Pseudo-code for error detection algorithm.

150. Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
     April 01, 2025 - The national consciousness of medical error was stirred by the landmark 1991 Harvard Medical Practice … Study 13,14  that described the epidemiology of medical error and reported on the incidence of adverse … As the field evolved to consider diagnostic errors as a subset of medical error, the term diagnostic … The goal of Safety-I is to prevent, avoid, minimize, or mitigate error and harm. … Unlike some error-focused terms, such as “diagnostic error,” that emphasize shortcomings, diagnostic

151. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship9.html
     August 01, 2024 - as a Model To Improve the Quality and Safety of Diagnosis Introduction Background Diagnostic Error … in the Testing Process Diagnostic Stewardship Interventions To Reduce Diagnostic Error Diagnostic … Given the pivotal role of diagnostic testing in medicine, programs and initiatives to reduce diagnostic error

152. Conclusions and Next Steps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-6.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Conclusions and Next … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Can we develop checklists for diagnostic error reduction that focus on errors of execution rather than … other critical questions and demonstrate if and how checklists can be a viable tool for diagnostic error

153. Appendix B. Search Terms | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appb.html
     March 01, 2017 - Patient Safety Patient safety Safety Safety culture Safety climate Medical error … Disclosure Adverse events Just culture Error reporting Reporting culture Communication … Error Harm Diagnostic error Defensive medicine Testing Leadership Safe care

154. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety6.html
     September 01, 2022 - Diagnosis and Suggested Questions for Debriefing Case Studies Committee on Diagnostic Error … Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call … Nurses, diagnosis, and diagnostic error. Diagnosis. 2017;4(4):197-199. doi: 10.1515/dx-2017-0027 . … Diagnostic error: safe and effective communication to prevent diagnostic errors .

155. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state-references.html
     January 01, 2024 - The incidence of diagnostic error in medicine. … What contributes to diagnostic error or delay? … Analysis of diagnostic error cases among Japanese residents using diagnosis error evaluation and research … Engaging Patients in Diagnostic Error Reporting. … Review of diagnostic error in anatomical pathology and the role and value of second opinions in error

156. Taxonomic Guidance for Remedial Actions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
     December 23, 2004 - do not directly cause the error. … The human error sub-subpath (human error how/why) is based to a large extent on the SRK approach described … Human Error. Cambridge: Cambridge University Press; 1990. 2. Norman D. … “SMART” error management in a radiotherapy quality system. … Medication error prevention “toolbox.” Medication Safety Alert, June 2, 1999.

157. Cuestionario sobre la seguridad de los pacientes en las farmacias en su comunidad (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-survey-spanish.docx
     June 02, 2025 - ► Un error es cualquier tipo de equivocación o error en el medicamento, o cualquier incidente relacionado … Cuando ocurre un error, tratamos de averiguar los problemas en los procesos que dieron lugar al error … Cuando un error sigue ocurriendo, cambiamos la manera en que se trabaja |_|1 |_|2 |_|3 |_|4 |_| … Cuando el paciente recibe un medicamento con algún error que podría causarle daño al paciente pero no … Cuando el paciente recibe un medicamento con algún error que no tiene la posibilidad de causar daño,

158. Final Progress Report: Communication to Prevent and Respond to Medical Injuries: WA State Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gallagher1-report.pdf
     January 01, 2024 - Participants in team communication and error disclosure training TEAM COMMUNICATION ERROR DISCLOSURE … following an error is unclear. … The “irregularly regular” nature of the incidence of error further complicates this. … Accountability for medical error: Moving beyond blame to advocacy. CHEST 2011;140:519-526. 2. … Error disclosure: A new domain for safety culture assessment BMJ Qual Saf.

159. Urinary Catheter Types and How To Care for Them Activity | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-insertion/unlicensed-staff/scenarios-instr.html
     March 01, 2017 - Some scenarios may have only one error while others will have more. … What can be done at our facility to help prevent this error or mistake in catheter care? … Error/Corrective Action: Hand hygiene was not performed upon entering or leaving the room. … Error/Corrective Action: Both staff members should be wearing gloves since both are handling either … Error/Corrective Action: Hand hygiene should always be performed when exiting a resident's room.

160. Final Progress Report: Real-time assessment of risk factors for medication errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/dresselhaus-report.pdf
     January 01, 2024 - During sampled intervals, 151 error reports were obtained involving 56 (29 physicians and 27 nurses) … Medical error has become a prominent concern since the Institute of Medicine (IOM) published To Err … In such cases, we will approximate error events to self-report ratings by aggregating across larger … However, they do permit some level of interpretive analysis, even with incomplete error data points. … During sampled intervals, 151 error reports were obtained involving 56 (29 physicians and 27 nurses)