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161. From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
     January 01, 2004 - The Error Tool Survey, also completed by team members, assessed the kinds of errors that were actually … processes (the differential recognition of error across disciplines); behavioral aspects (perception … At times, they noted the need for more aggressive management but use of the word “error” or “mistake … Only about two-thirds of them, however, would tell the patient about this error. … An error by any other name. Am J Nurs 2004;04(6):32– 43;quiz 44. 4. Cook AF, Hoas H.

162. Why Did It Happen? | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
     June 01, 2018 - Apply CUSP To Find Out Why Error Occurred [34 sec.]

163. Improving Antibiotic Use is a Patient Safety Issue
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/patient-safety-slides.pptx
     November 01, 2019 - Human Error. Cambridge: Cambridge University Press; 1990. … Human Error. Cambridge: Cambridge University Press; 1990. … Human Error. Cambridge: Cambridge University Press; 1990. … Human Error. Cambridge: Cambridge University Press; 1990. … Human Error. Cambridge: Cambridge University Press; 1990.

164. Cuestionario sobre la seguridad de los pacientes en las farmacias en su comunidad (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-survey-spanish.pdf
     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 5 9 6. … Cuando el paciente recibe un medicamento con algún error que podría causarle daño al paciente pero … Cuando el paciente recibe un medicamento con algún error que no tiene la posibilidad de causar daño

165. Final Progress Report: Acute Care Learning Laboratory - Reducing Threats to Diagnostic Fidelity in Critical Illness (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/pickering-report.pdf
     January 01, 2025 - Key Words: diagnosis error, sociotechnical systems, mix methods, systems engineering. 2 1. … What Contributes to Diagnostic Error or Delay? … The challenges in defining and measuring diagnostic error. Diagnosis (Berl). … The incidence of diagnostic error in medicine. BMJ Qual Saf. … What Contributes to Diagnostic Error or Delay?

166. MEASUREMENT OF DIAGNOSTIC ERRORS IS THE FIRST STEP TO IMPROVEMENT (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/singh-summit2016.pdf
     September 01, 2016 - diagnosis”  lack of standards for most “diagnosis” concepts  Operational definitions of diagnostic error … missed opportunities that warrant additional clinical evaluation  Stronger signals to bolster error … 2011Singh et al JAMA IM 2012; Singh and Sittig BMJQS 2015; Singh et al Peds 2010 Approach Diagnostic “Error … Progress Safer Dx Measurement Framework Time Ripe for Retrospective Measurements Approach Diagnostic “Error

167. Appendix B. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/demo-program/grants/appb.html
     August 01, 2022 - Liability claims and costs before and after implementation of a medical error disclosure program. … The Error Disclosure Culture Survey and its implications for organizational culture.

168. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-100813.ppt
     January 01, 2013 - National Coordinating Council for Medication Error Reporting and Prevention A – I Error Severity Taxonomy … Blameless error, corrective training, counseling indicated Blameless error NO Culpable Gray … Feedback & Communication about Error Feedback & Communication about Error Nonpunitive Response to Error … Nonpunitive Response to Error Nonpunitive Response to Error Staffing Staffing Staffing Hospital Management … Feedback & Communication about Error Feedback & Communication about Error Nonpunitive Response to Error

169. Looking for Trouble in All the Right Places: The Legal Implications Associated with “Electronic Signatures” and High-risk Clinical Situations (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Escobar.pdf
     February 01, 2005 - and error-reporting systems in health care organizations. … Medication errors are important, but they are not the only kind of error in medicine. … detection, error reduction, and quality improvement processes. … No-fault compensation for medical injuries: the prospect for error prevention. … Error in medicine: legal impediments to U.S. reform.

170. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
     May 01, 2003 - Medical error: a discussion of the medical construction of error and suggestions for reforms of medical … education to decrease error. … Medical error: the second victim. BMJ 2000;320(7237):726–7. 13. … Understanding medical error and improving patient safety in the inpatient setting. … Improving medication administration error reporting systems. Why do errors occur?

171. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2024.xlsx
     January 01, 2024 - The tables include the relative frequencies by type of device, by device defect, failure or use error … Percentage Frequency Unknown 57.5% 22,873 Device defect or failure, including HIT 29.6% 11,791 Use error … 8.9% 3,534 Combination or interaction of device defect or failure and use error 4.0% 1,574 Device … Frequency Unknown 95.1% 5,134 4.7% 253 Device defect or failure, including HIT 92.5% 3,604 7.2% 263 Use error … 87.5% 1,255 13.0% 189 Combination or interaction of device defect or failure and use error 88.0% 611

172. Diagnostic Safety Research (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/DiagnosticSafety-flier.pdf
     November 01, 2024 - 1 Diagnostic Safety Research at the Agency for Healthcare Research and Quality Diagnostic Error … Diagnostic error is a significant and underrecognized threat to patient safety. … and add to inequities in health outcomes.2-10 ■ Delayed or missed diagnosis of cancer is a common error … Burden of serious harms from diagnostic error in the USA. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

173. Special Considerations for Measurement of Diagnostic Safety (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2b.html
     June 01, 2020 - For example, reports from clinicians who have witnessed diagnostic error have the advantage of rich detail … Synthesizing Data and Enhancing Confidence in Measurement Determining the presence of diagnostic error … or no error) may be insufficient for cases involving greater uncertainty, which call for more graded … assessment approaches reflecting varying degrees of confidence in the determination of error. 20,94 … Other factors related to diagnostic error, such as the presence of patient harm (e.g., clear evidence

174. Breakout 2 (afternoon): Use of Data and Measurement in Reducing Error (video) | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-agenda/breakout2-video.html
     August 01, 2017 - Breakout 2 (afternoon): Use of Data and Measurement in Reducing Error (video) YouTube embedded

175. Breakout 1 (morning): Use of Data and Measurement in Reducing Error (video) | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-agenda/breakout1-video.html
     August 01, 2017 - Breakout 1 (morning): Use of Data and Measurement in Reducing Error (video) YouTube embedded

176. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - Categorization of diagnostic error Historically, diagnostic error was seen at an individual level as … Cognitive error includes both errors of ignorance and implementation. … usually associated with less knowledge-based thinking (medication error, procedural error, and others … Human error. Cambridge, UK: Cambridge University Press; 1990. 22. Hammond KR. … A case study in medical error: the use of the portfolio entry.

177. Final Progress Report: Partnering With Patients To Find Adverse Events (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/weingart2-report.pdf
     January 01, 2024 - The presence of any service quality deficiency more than doubled the odds of any adverse event or error … Patient safety, medical error, patient-physician communication, information technology. … Medical error is prevalent in healthcare. … ’s performance is an unwieldy method for error measurement [6]. … Epidemiology of medical error. BMJ 2000; 320: 774-7. 3.

178. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - do not catch the initiating error. … Human error in hospitals and industrial accidents: current concepts. … A methodology for modeling operator error in probabilistic risk assessment. … Operating at the sharp end: the complexity of human error. In: Bogner MS, editor. … Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum; 1994. pp.255–310. 19.

179. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/org_embrace-slides/Organizational-Embrace-of-CUSP-to-Improve-Patient-Safety-Mar-20-2012-508.ppt
     January 01, 2012 - teams Staff retention and performance Pay structure and clinical ladder Decreased agency Web-based error … 58.20% 42.93% 51.59% 49.03% 70.30% 56.68% 82.61% 62.65% 59.77% 66% 71% 76% Feedback and comm about error … 45.39% 42.98% 48.70% 26.06% 39.26% 57.94% 67.82% 29.37% 44.34% 44% 51% 60% Nonpunitive response to error … 58.20% 42.93% 51.59% 49.03% 70.30% 56.68% 82.61% 62.65% 59.77% 66% 71% 76% Feedback and comm about error … 45.39% 42.98% 48.70% 26.06% 39.26% 57.94% 67.82% 29.37% 44.34% 44% 51% 60% Nonpunitive response to error

180. A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
     June 11, 2003 - of Safety” led to a paradigm shift in assessing an individual’s performance, event occurrences, and error … Prior to the patient safety initiative, under the then-existing error reporting system, staff members … This delay and the lack of timely feedback to hospital staff could lead to reoccurrence of an error. … The hospital had to undertake a paradigm shift in the way it assessed individual performance and error … The survey results found that 90 percent of the staff felt confident in their error reporting.