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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.
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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
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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.
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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.
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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
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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.
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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.
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www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/schiff-summit2016.pdf
January 01, 2013 - Delayed diagnosis
Safer practice can only come
about from acknowledging the
potential for error … and building
in error reduction strategies at
each stage of clinical practice
Lucian Leape
DEER … Slide Number 3
Slide Number 4
Safer practice can only come about from acknowledging the potential for error … and building in error reduction strategies at each stage of clinical practice�� Lucian Leape�
Slide … Acrobat Accessibility Report
Accessibility Report
Filename:
REVISED Diagnosis Error
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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
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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.
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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%
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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
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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
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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
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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
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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
-
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
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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.
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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
-
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?