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181. 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

182. 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.

183. 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

184. 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

185. 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

186. 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.

187. 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.

188. 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.

189. 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.

190. 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

191. Methodological Challenges in Describing Medication Dosing Errors in Children (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
     January 01, 2004 - medication errors that occur, the clinical importance of these errors, or effective strategies for error … This would provide a conservative estimate of medication dosing error rates. … Therefore, it is difficult for pharmacies to correctly determine if a weight-based dosing error has … Medication error prevention by clinical pharmacists in two children’s hospitals. … The impact of computerized physician order entry on medication error prevention.

192. Final Progress Report: Staff Nurse Fatigue and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/rogers-report.pdf
     January 01, 2024 - Working longer than 12.5 consecutive hours was associated with a significantly higher risk of error, … Short sleep durations were also associated with an increased risk of making an error and difficulties … and almost doubled the risk of making error among critical care nurses (AACN Sample). … Fatigue, performance, and medical error. In: Bogner MS, ed. Human error in medicine. … Human error in medicine. Hillsdale, N.J.: Lawrence Erlbaum Associates; 1994:13-25. 12.

193. Rationale for Use | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-2.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Rationale for Use … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … We will discuss the evidence for the effectiveness of checklists for diagnostic error reduction and factors

194. Resources Related to Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/index.html
     March 01, 2025 - Issue Briefs Journal Articles Diagnostic error in mental health: a review .  … Defining diagnostic error: a scoping review to assess the impact of the national academies' report improving … You can search diagnostic error to find related studies and resources.

195. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
     April 03, 2008 - Introduction Although error reporting has been widely substantiated in the literature as an integral … • Promoting a fair and just culture for error reporting. … Differing definitions of actual and potential error • Providing unit-based in-services. … Time/effort required for error reporting • Implementing the End-of-shift Safety Report. … Voluntary medication error reporting program in a Japanese national university hospital.

196. Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Zhang.pdf
     January 01, 2004 - [Message] Good error messages. … [Error] Prevent errors. … cause error.25, 26 For example, an isolated step in a task affords error, such as the step of entering … internal, the higher the error affordance because internal representations are more error prone. … Medical Device Usage Errors 335 established a strong correlation between error affordance and error

197. Grand Rounds Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
     August 01, 2022 - programs, but many struggle to ensure that solutions to errors are really addressing the cause of the error … and not just checking the box on their process when they do their analysis of the error. … In Rosemary Gibson's book: Responding to medical error is a part of health care where we should be … Being shamed or blamed for the error. Revealing poor skills/abilities.   … This is a cornerstone of the CANDOR process of investigating the root cause of how an error occurred,

198. Rationale for Improvement Tools | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-3.html
     September 01, 2021 - Immediately After Childbirth: State of the Science Introduction The Contribution of Diagnostic Error … underrecognition occurs is needed to inform targeted approaches to address this important diagnostic error … process issues. 35–37 Simulation can also be used to identify, understand, and address diagnostic error … misinterpretation, as well as system errors (latent safety threats), to support reduction in diagnostic error … Simulation can be a useful modality for addressing diagnostic error in maternal health by facilitating

199. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-7.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction References … Previous Page   Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Debiasing versus knowledge retrieval checklists to reduce diagnostic error in ECG interpretation. … Developing checklists to prevent diagnostic error in Emergency Room settings. … Human Error. Cambridge, UK: Cambridge University Press; 1990. Return to Contents

200. 1. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state1.html
     January 01, 2024 - care. 1-9 For example, an estimated 5 percent of the U.S. adult population experiences a diagnostic error … setting every year, 1 and approximately 0.7 percent of inpatients experience harm from a diagnostic error