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201. 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

202. Looking for Trouble in All the Right Places: The Legal Implications Associated with “Electronic Signatures” and High-risk Clinical Situations (pdf file)
     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.

203. Brain Based Learning
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2017-materials/teamstepps_webinar_012017.pptx
     January 01, 2017 - detection, and how best to manage the error, or error recovery. … Phase 1– Obvious Error Detection in Others (misattribution theory) Interactive Videos, Simulations, … Phase 4—Subtle Self Error Detection Creative ways to introduce errors are necessary Competition among … Management Theory Phase 5—Error Recovery When an error is detected, an appropriate protocol is offered … TEAMSTEPPS 05.2 Mod 1 2.0 Page ‹#› Brain Based Learning Strategies Page ‹#› Error Management Theory

204. 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.

205. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/21093-Lambert-draft-1.pdf
     November 20, 2017 - 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.

206. Closing Gaps in Research ~ Organizationsand Healthcare Diagnoses (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/goeschel-summit2016.pdf
     October 05, 2016 - errors and near misses in clinical practice 8 Goals to Improve Diagnosis and Reduce Diagnostic Error … Priorities for Organization Focused Research 1: How to tie NAM recommendations to existing work Dx Error … Slide Number 6 8 Goals to Improve Diagnosis and Reduce Diagnostic Error 8 Goals to Improve Diagnosis … and Reduce Diagnostic Error Three Pragmatic Challenges and Priorities for Organization Focused Research … Acrobat Accessibility Report Accessibility Report Filename: Goeschel AHRQ Dx Error

207. Rationale for Use | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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

208. 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

209. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions1.html
     June 01, 2023 - Inpatient-to-Outpatient Transitions Next Steps and a Call to Action References Diagnostic error … Transitions of care with potential for diagnostic error In healthcare and other industries, transitions … commission, communication errors may follow similar patterns and are particularly relevant to diagnostic error … and Transfer of information. 5 However, few strategies focus specifically on reducing diagnostic error

210. Using Just Culture to Improve Hospital Survey on Patient Safety Culture Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-intro.html
     January 01, 2017 - Feedback & communication about error. Frequency of event reporting. Handoffs & transitions. … Nonpunitiveresponse to error. Organizational learning—continuous improvement. … quality-patient-safety/patientsafetyculture/hospital/hosp-reports.html Defining Nonpunitive Response to Error … Nonpunitive Response to Error Survey Items Staff feel like their mistakes are held against them.

211. 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

212. 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.

213. 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.

214. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses1.html
     August 01, 2022 - high-risk environment where physicians and nurses are particularly susceptible to making a diagnostic error … errors. 4 The National Academies of Sciences, Engineering, and Medicine (NASEM) defines diagnostic error … or (b) communicate that explanation to the patient.” 5 Even a conservative estimate of diagnostic error … occurring in 5 percent of ED visits translates to about 7 million cases of ED-based diagnostic error

215. 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.

216. 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.

217. Nurses' Role in Diagnosis, Through the Lens of Distributed Cognition | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses3.html
     August 01, 2022 - Areas for Future Research Conclusion References The landmark report on diagnostic error … Any shortcomings in eliciting all relevant information from a patient can contribute to diagnostic error … perspective and language use contribute to framing effects and context errors that may lead to diagnostic error

218. Final Progress Report: Communication to Prevent and Respond to Medical Injuries: WA State Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/gallagher-report.pdf
     August 01, 2014 - 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.

219. 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.

220. 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