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181. Diagnostic Safety Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/grants-2022.html
     March 01, 2024 - 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 … DECODE: Diagnostic Excellence Center on Diagnostic Error Principal Investigators: Ramin Khorasani … Evaluate the structure, process, and outcome effects of human-centered solutions on diagnostic error … Develop site-level and groupwide benchmarking reports of error rates, diagnostic processes, and diagnostic

182. 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.

183. 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.

184. 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.

185. Taxonomic Guidance for Remedial Actions (pdf file)
     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.

186. Cuestionario sobre la seguridad de los pacientes en las farmacias en su comunidad (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-survey-spanish.docx
     July 17, 2024 - ► 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,

187. Urinary Catheter Types and How To Care for Them Activity | Agency for Healthcare Research and Quality
     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.

188. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
     www.ahrq.gov/downloads/pub/advances/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.

189. 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.

190. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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

191. References | Agency for Healthcare Research and Quality
     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

192. 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.

193. Silence A Commentary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/liability/silence.html
     August 01, 2017 - and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Error … This is what it feels like when you lose a loved one to a medical error. … , a systems error, or both. … In the past, patients experienced only silence and abandonment after a medical error. … The many faces of error disclosure: A common set of elements and a definition .

194. Final Progress Report: Addressing Preventable Medication Use Variance in Mississippi (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/11923-Brown-draft-1.pdf
     September 01, 2006 - "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.”

195. Final Progress Report: Communication to Prevent and Respond to Medical Injuries: WA State Collaborative (pdf file)
     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.

196. Diagnostic Stewardship Interventions To Reduce Diagnostic Error | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship5.html
     August 01, 2024 - Improve the Quality and Safety of Diagnosis Diagnostic Stewardship Interventions To Reduce Diagnostic Error … 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 … with tracking, followup, and interpretation of completed test result reports contribute to diagnostic error

197. 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?

198. Final Progress Report: The Effect of EMR on Medication Safety: A SPUR-Net Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14406-Kuo-draft-1.pdf
     March 01, 2005 - 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.

199. 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?

200. 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