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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 .
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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
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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
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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.
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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
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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
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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,
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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.
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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.
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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)
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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.]
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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.
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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.
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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.
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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
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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.
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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
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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
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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.
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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?