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  1. 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.
  2. 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
  3. 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.
  4. 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.
  5. 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
  6. 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.
  7. 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.
  8. 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
  9. 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
  10. 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.
  11. 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%
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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.
  19. 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
  20. 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?

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