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221. 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.

222. 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

223. 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

224. 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.

225. /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.

226. 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.

227. 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.

228. 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/dx-safety-issue-brief-co-design-rev.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.

229. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
     June 01, 2023 - from patients and families, one cannot simply ask respondents if they have experienced a diagnostic error … ” or “diagnostic error” within the survey. … ” or “diagnostic error” when inviting reports about patient experiences, the preferred alternative is … We also asked about clinician actions following the perceived medical error that “made things worse.” … Not one damn thing [to make things better following the error].

230. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
     July 01, 2023 - ” or “diagnostic error” within the survey. … Not one damn thing [to make things better following the error]. … following the medical error.” … The Public’s Views on Medical Error in Massachusetts. … Patients’ perspectives of diagnostic error: a qualitative study.

231. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
     March 01, 2002 - Medication error reporting is an essential component of achieving these goals. … Level C excludes drug-related injuries that are not the result of error. … error, transcription error, prescribing error, charting error, and a miscellaneous “other” category … 17 (7.5) 0 (0) 17 (6.3) Transcription error 17 (7.5) 10 (25.0) 27 (10.0) Prescribing error 13 (5.7 … Current error reporting systems.

232. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
     July 01, 2022 - Diagnostic error in internal medicine. … What factors prompted the error discovery? … No Harm � Category A- Circumstances or events that have the capacity to cause error Error, No Harm … � Category B- An error occurred but the error did not reach the patient (An “error of omission” does … occurred that required intervention necessary to sustain life Error, Death � Category I- An error occurred

233. 1. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state1.html
     January 01, 2024 - care. 1-9 For example, an estimated 5 percent of the U.S. adult population experiences a diagnostic error … setting every year, 1 and approximately 0.7 percent of inpatients experience harm from a diagnostic error

234. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/tools/index.html
     June 01, 2025 - primary care offices consistently show that the process for managing tests is a significant source of error … a checklist and other resources to help patients understand what they can to do prevent diagnostic error … Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error

235. Device or Medical/Surgical Supply Dashboard | Agency for Healthcare Research and Quality
     www.ahrq.gov/npsd/data/dashboard/devices.html
     September 01, 2025 - the type of device; type of device by residual harm to the patient; device defect, failure, or user error … ; device defect, failure, or user error by residual harm to the patient; type of health information technology

236. Agency for Healthcare Research and Quality | Agency for Healthcare Research and Quality
     www.ahrq.gov/cpi/about/mission/ahrq-fy2015-conf-spending.html
     January 01, 2016 - Total Non-Feds on Travel:  0 Center for Quality Improvement and Patient Safety (CQUIPS) Diagnostic Error … and final of three annual conferences to be held as part of the large conference grant "Diagnostic Error … response to the AHRQ funding mechanism PAR09-257 and supports the AHRQ/CQUIPS program to reduce medical error

237. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - A Heparin Error Reduction Workgroup (HERW)—consisting of staff nurses, pharmacists, and a cardiologist—was … The analysis also identified several sources of potential error, particularly in situations in which … The potential sources of error and recommended actions are discussed in the following subsections of … Potential sources of error Confusing protocol selection. … A Heparin Error Reduction Workgroup was convened to address the issue.

238. Current State of Diagnosis Education | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-3.html
     March 01, 2022 - Clinical reasoning is challenging and represents the dominant issue in diagnostic error, as repeated … advancing healthcare careers) has important gaps in many other areas relevant to diagnosis and diagnostic error … Breakdowns in collaboration and teamwork are leading system-related issues in cases of diagnostic error … improving diagnosis education was an "ethical imperative," given the aggregate harm from diagnostic error

239. Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
     April 30, 2022 - Category: Delta (% Positive - % Negative) Scores Slope: Pattern Communication Response to Error … IP O VE R AL L Key takeaways: Positive:  Report, communication, learning and response to error … 2024 SOPS Survey -- 323 responses 36 v Communication 323 72% 19% 9% 73% 64% | 9% > Response to error … 318 68% 19% 13% 68% 60% | 8% > Communication about error 310 74% 21% 5% 74% 70% | 4% > Communication … 1.9-2.2) 40 TENTS vs Patient Safety Survey (Communication; 1 unit data only) Communication about error

240. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-1.html
     September 01, 2021 - Immediately After Childbirth: State of the Science Introduction The Contribution of Diagnostic Error … consensus has been reached on what extent maternal mortality and SMM are attributable to diagnostic error … diagnostic errors. 2 , 12 This issue brief discusses what is known about the contribution of diagnostic error