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141. 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.

142. 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

143. 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

144. 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

145. 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

146. 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

147. 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.”

148. 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.

149. 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.

150. 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

151. 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.

152. 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.

153. 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.

154. 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

155. 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
     July 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

156. 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

157. 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.

158. 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.

159. 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.

160. 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