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221. 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

222. 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

223. 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

224. 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.

225. 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

226. 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

227. 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.

228. 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?

229. 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.

230. 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

231. 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

232. 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.

233. The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Galt.pdf
     January 01, 2005 - prescribing [e- prescribing], or both) that was responsible for influencing the error. … Potential impact of PDA application on type of prescribing error Provides opportunity to reduce error … This improves our ability to understand and compare data from error studies. … Fundamentals of medication error research. Am J Hosp Pharm 1990;47:555–71. 34. … Potential impact of PDA application on type of prescribing error Table 2.

234. Christiana Care Health System: Safety Mentor Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell_94.pdf
     March 30, 2008 - A staff survey in 2001 showed that there were opportunities for improvement related to error reporting … Staff across the board felt they had responsibility for error prevention but viewed the error-reporting … Survey respondents also expressed fear of the consequences of being associated with an error. … However, the best technology alone will not eradicate error. … Only 55 percent of respondents felt that error reporting was widely encouraged and nonpunitive.

235. SOPS Nursing Home Survey: What You Need To Know - Nicholas Castle, Ph.D., M.H.A., FGSA (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
     January 01, 2006 - between 44,000 and 98,000 individuals die each year as a result of medical mistakes. 17 Medical Error … Human Error 1990 Patient Safety Culture in Nursing Homes • Safety culture scores are lower on average … 25 The Importance of Safety Culture in Nursing Homes The Importance of Safety Culture Medical Error

236. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072320.pdf
     November 06, 2020 - • PSNet: Published a primer on 7/22/20 called COVID-19 and Dx Error. … grant=R01+HS27614-01 https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error … https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error https://www.cdc.gov … • Recently Published Diagnostic Safety Relevant Papers: o Reducing the Risk of Diagnostic Error in … www.journalofhospitalmedicine.com/jhospmed/article/222266/hospital-medicine/reducing-risk-diagnostic-error-covid

237. /docProps/thumbnail.jpeg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module3/facnotes-spanish.docx
     June 02, 2025 - Es posible que se necesite un proceso de prueba y error para implementar sistemas viables. … DIAPOSITIVA 18 DIGA: En el video a continuación, Sharon le menciona un error al jefe de enfermería … sobre los errores a fin de volver a examinar el procedimiento y descubrir la causa del error. … Es importante que la respuesta al error no sea una sanción. … que el error era una oportunidad para aprender y no un perjuicio deliberado por parte de Sharon.

238. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-7.html
     March 01, 2022 - Diagnostic error in internal medicine . Arch Intern Med. 2005;165(13):1493-9. … Diagnostic error in medicine—analysis of 583 physician-reported errors . … Cognitive interventions to reduce diagnostic error: a narrative review . … The patient is in: patient involvement strategies for diagnostic error mitigation . … Nurses, diagnosis, and diagnostic error . Diagnosis (Berl). 2017;4(4):197-9.

239. Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
     December 01, 2012 - Managing Error and Risk Slide 8. … Can you identify examples of human error in your unit or hospital? … Managing Error and Risk   Say: To improve outcomes, human error, at-risk behavior, and reckless … Human error is a product of both system design and behavioral choices. … Describe the connections between communication and medical error.

240. The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-patient-role.pdf
     September 01, 2024 - independent national advocate for patients and families Helen Haskell, M.S., Mothers Against Medical Error … Patients and caregivers who have experienced a diagnostic error can provide a unique perspective. … Goals for Improving Diagnosis and Reducing Diagnostic Error • Facilitate more effective teamwork in … Burden of serious harms from diagnostic error in the USA. … The patient is in: patient involvement strategies for diagnostic error mitigation.