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201. Re-engineering for Accurate, Timely, and Communicated Diagnosis of Cardiovascular Disease in Women (DREAM Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/dream-lab-long-desc.html
     August 01, 2025 - reports, and applied natural language processing and machine learning to identify patterns in diagnostic error … proactive patient engagement strategies. 4 The lab also created a revised version of the DEER (Diagnostic Error … Defining diagnostic error: A scoping review to assess the impact of the National Academies’ report Improving … Defining diagnostic error: A scoping review to assess the impact of the National Academies' report Improving

202. Final Progress Report: Blood Product Transfusion & Safe Practices (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/herwaldt-report.pdf
     January 01, 2024 - This function tracks Error Flag, PID, Sample ID, Requisition ID, Order Card ID, date/time, Error Message … Correct error before proceeding NoAll scans match? … Correct error before proceeding Correct error before proceeding Complete tests, type/screen as ordered … Correct error before proceeding Step 4. … Prevented Error = Mismatch between two different, valid Patient IDs Skipped Step = An upstream scan

203. AHRQ Research Summit Wrap-up (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/epner-summit2016-wrapup.pdf
     September 28, 2016 - Improve Diagnosis in Medicine • Vision Creating a world where no patients are harmed by diagnostic error … Improve Diagnosis (CID) • CID aims to bring much-needed attention, awareness and action to diagnostic error … effective tools for improving diagnostic performance and reducing harm associated with diagnostic error … Awareness Campaign 10 • Objectives  Drive awareness and attention to the problem of diagnostic error … in an effort to put diagnostic error prominently on the nation’s health radar  Drive engagement intended

204. Connecting the Dots: Improving Unit Safety Culture to Stop HAI | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/connecting-dots-slides.html
     December 01, 2017 - culture 3 : Our processes are designed to prevent failure We are committed to detect and learn from error … support and reward reporting; discipline occurs based on risk-taking Nonpunitive Response to Error … item 2 Composites all items reverse-worded: Handoffs & Transitions Nonpunitive Response to Error … National Coordinating Council for Medication Error Reporting and Prevention A–I Error Severity Taxonomy … Four items elicit perceptions of feedback about error.

205. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
     March 01, 2020 - intended to answer one primary question, “What PSPs can assist in decreasing patient identification error … Site" OR "Medical Mistake*" OR "Disclosure of Error*" OR "Mental Error*" OR "Action Error*"))) … Patient Surger*" OR "Wrong- Patient Surger*" OR "Wrong Procedure Error*" OR "Wrong- Procedure Error … *" OR "Mental Error*" OR "Action Error*") AND ((MH "Operating Rooms") OR (AB "Operating Room … Patient Identification Error in the Operating Room Search Terms

206. The Potential of Psychological Safety and Organizational Safety Culture To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-2.html
     September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … It is reasonable, however, to think that the principles that enable error reporting and guide process

207. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Error … Each reported error was coded with just one primary error but with up to four additional associated or … reporting, and the psychological barriers to admitting involvement in an error in patient care. … "Every error counts": a web-based incident reporting and learning system for general practice. … Does error and adverse event reporting by physicians and nurses differ?

208. Factors That Influence Effectiveness of Checklists | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-4.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Factors That Influence … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … cases as well. 18 Checklists may be more effective in difficult cases because there is more room for error

209. Post-fielding Surveillance of a Guideline-based Decision Support System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
     January 01, 2004 - requires careful attention to the vulnerabilities of any system.1 Table 1: Potential sources of error … Free text comments were investigated as potential sources of error in the program or its data sources … In most cases, clinician reports were false positives for error. … Incorrect adverse drug reaction (ADR) notification 1 Error in the data conversion, leading to the … Computer decision support as a source of interpretation error: the case of electrocardiograms.

210. Discussion of Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/findings.html
     March 01, 2017 - were followed by issues surrounding medication prescribing, management, and adherence and diagnostic error … Medication Issues One of the most widely studied sources of medical error in both acute and nonacute … Each of these gaps in medication safety has yielded different approaches to reduce opportunity for error … Diagnostic Error Estimates of diagnostic error in outpatient care suggest that approximately 1 in 20 … Ultimately, diagnostic error relates to the principle of uncertainty inherent in the diagnostic process

211. Final Progress Report: Creating Learning Cultures Around Mistakes for Residents (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
     January 01, 2024 - hierarchy and outcome over process, the nature of resident and attending responses to the act of error … Willingness to develop logics that link contextual factors to increased probability for the error or … events in a way that questions the underlying assumptions upon which the work leading to that error … The study comparatively examined three error-prone medical residency settings through a single-case, … However, it decreased the presence of specific learning best practices around error such as inquiry

212. Understanding SOPS Surveys: A Primer for New Users (Webcast) - Gray (Overview) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-SOPS_101_Webcast-GRAY-Overview.pdf
     June 02, 2025 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management … in medical offices supports accurate diagnoses ► Assist in identifying processes and sources of error

213. Webcast: Using Just Culture To Improve Hospital SOPS Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/sops/events/webinars/just-culture.html
     December 01, 2018 - scores on the Hospital Survey on Patient Safety Culture , particularly the Nonpunitive Response to Error

214. Identifying Barriers to the Success of a Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
     March 01, 2004 - Abstract Spurred by a controversial report from the Institute of Medicine on the prevalence of medical error … previously unknown, but safety-critical information for developing a proactive approach to managing human error … Introduction “The most detrimental error is failing to learn from an error.”1 The past decade has … Fueled by a report from the Institute of Medicine (IOM) suggesting that human error is responsible for … Human error. New York: Cambridge University Press; 1990. 2.

215. Improving the Safety of Diagnosis and Therapy in the Inpatient Setting | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
     February 01, 2024 - Problem analysis using systems engineering methods to analyze the problem of diagnostic and therapeutic error … reassessing the diagnosis of patients (i.e., inside or outside their hospital rooms) when risk for diagnostic error … A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis … Identifying and assessing diagnostic error in acute care: is the electronic health record telling us … A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis

216. Final Progress Report: : State of the Science on Safe Medication Administration (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/barnsteiner-report.pdf
     January 01, 2024 - • How do differing definitions of “error” among providers and administrators affect error reporting, … • Can a taxonomy of errors improve error reporting? … • What is the relationship between nurse fatigue and error rate? … • Does the dissemination of error reports influence subsequent error reporting and rates? … • How do staffing ratios and staff stability (turnover rate) affect error rates?

217. Final Progress Report: Leveraging Existing Assessments of Risk Now (LEARN) Final Report (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
     January 01, 2025 - Risk Assessment C.5.a Error Science and Medicine The study of error and safety in the 20th century … If info is wrong, the Fenwal armband on patient will catch the error. … risk of error in the care of a pediatric patient. … Human Error. Cambridge University Press: New York, 1990. 7 Norman D. … Promoting Patient Safety and Preventing Medical Error in Emergency Departments.

218. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-about-cusp-fac-guide.html
     July 01, 2023 - Can you identify examples of human error in your unit or hospital? … Slide 16: Managing Error and Risk 3 Say: To improve outcomes, human error, at-risk behavior, and … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console providers who have committed a human error and to ensure

219. Appendix E | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
     April 01, 2018 - Errors 18 408  -- Clinical Misdiagnosis 0 410  -- Diagnostic Test Interpretation Error … 2 409  -- Radiograph Interpretation Error 1 412 Discontinuities, Gaps, and Hand-Off …  -- Simulators 0 669  -- Students 0 676  -- Teamwork Training 0 619 Error … Reporting and Analysis 206 625  -- Error Analysis 185 627  ---- Failure Mode Effects … 626  ---- Root Cause Analysis 73 688  ---- Patient Safety Indicators 3 620  -- Error

220. Producing Accurate Clinical Quality Reports for Population Health: A Delivery System-Oriented Approach to Report Validation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/ehr-reports.pdf
     March 01, 2016 - .........14 Case Study..............................................................14 Sources of Error … ....15 Inclusion Errors ............................................................16 Inclusion Error … One by one, the Medical Director and her DBA figured out and corrected the cause of each error. … Once an error is found, it is important to document the information both by the nature of the error … Inclusion Error Examples 1.