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181. 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.

182. 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

183. 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.

184. 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.

185. 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.

186. 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

187. 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,

188. 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

189. 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

190. Final Progress Report: Application of Machine Learning to Enhance e-Triggers to Detect and Learn from Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/singh-report.pdf
     January 01, 2025 - Key Words: Diagnostic error, machine learning 2. … Test Hypothesis 2 (supervised ML improves performance of diagnostic error e-triggers): a. … Development of a Machine Learning Enhanced Trigger to Detect Diagnostic Error [abstract]. … Emergency medicine: a practice prone to error?. … The incidence of diagnostic error in medicine.

191. Appendix F. Algorithms | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ssi/ssiapf.html
     April 01, 2018 - Correlation and Cross-validation error for CABG Algorithm Return to Contents Figure 3. … Correlation and Cross Validation Error for Herniorrhaphy Return to Contents Figure 5. … Correlation and Cross Validation Error for TKA Return to Contents Figure 7. … Correlation and Cross Validation Error for THA Return to Contents Algorithms That Include sSSI

192. Mod01-Grand-Rounds-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - 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 most … An explicit statement that an error occurred. 2. … ■ Being shamed or blamed for the error. ■ Revealing poor skills/abilities. … Slide 23 Say: Eliminating human error is a futile goal, as it is not a realistic approach.

193. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - 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 most … Being shamed or blamed for the error. Revealing poor skills/abilities. … Distinguishes between human error (console), at-risk behavior (coach), reckless behavior (punish). … Human error cannot be eliminated. Futile goal. Misdirects resources/focus.

194. Apply Module Slide Presentation Text Descriptions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/apply/alt-text.html
     March 01, 2013 - Slide 6 Understanding Risk and Human Behavior 1 Human Error: Inadvertently completing … disregard a substantial and unjustifiable risk Go to Slide Content Slide 7 Managing Error … and Risk 1 Human Error Product of our current system design and behavioral choices Manage … Human error is the product of our current system design and behavioral choices. … Consolation is the appropriate response to human error.

195. Challenges to Real-Time Decision Support in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
     January 01, 2007 - Studies have demonstrated that formal trauma patient algorithms encourage consistency, reduce error … retrospective, subjective judgment of error.13 Implementation Issues Algorithms A new approach … The video audit is used to verify compliance, error rates, and subsequent patient outcomes. … On error management: Lessons from aviation. Br Med J 2000; 320: 83-102. 6. … Human error. New York: Cambridge University Press; 1990. 17. Morey JC.

196. Tool: Cross-Monitoring | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/situation/tools/monitoring.html
     June 01, 2023 - Cross-monitoring is a harm and error reduction strategy that involves: Monitoring actions of other … Instead, it is a way to provide a safety net or an error prevention or error interruption mechanism for

197. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Why Checklists for … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Successful checklists for preventing other error types list very specific tasks.

198. SOPS State Hospital Association Webcast - Bakdash Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-sops-hospital-survey-workplace-item-set-webcast-bakdash.pdf
     December 01, 2024 - and Work Pace (4 items) • Organizational learning – Continuous Improvement (3 items) • Response to Error … • Supervisor, Manager or Clinical Leader Support for Patient Safety (3 items) • Communication About Error … Communication About Error Your Hospital 73% 1%Data Base … Response to Error Your Hospital 63% -1%Data Base 64%

199. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-4.html
     June 01, 2020 - Barriers and Taking Next Steps Conclusion References While measurement of diagnostic error

200. A Path Forward for Diagnostic Safety Improvement Leadership | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-5.html
     June 01, 2021 - References Despite the enormous financial cost and patient harm resulting from diagnostic error