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  1. 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 .
  2. 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
  3. 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
  4. 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.
  5. 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
  6. 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
  7. 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,
  8. 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.
  9. 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.
  10. 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)
  11. 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.]
  12. 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.
  13. 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.
  14. 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.
  15. 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
  16. 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.
  17. 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
  18. 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
  19. 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.
  20. 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?

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