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241. 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

242. Diagnostic Safety Research Priorities and Opportunities | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-4.html
     August 01, 2023 - NAM report Improving Diagnosis in Healthcare highlighted the critical deficiencies in diagnostic error … The report identified four broad priority research topics related to diagnostic error 60 : Patient … children’s conditions compared with their own. 39 Partnership with parents in preventing diagnostic error

243. AHRQ Issue Brief: Diagnostic Error's Impacts on Maternal Morbidity and Mortality | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/diagnostic-errors-issue-brief.html
     October 01, 2021 - Immediately After Childbirth: State of the Science , emerging evidence suggests that that diagnostic error … This issue brief discusses what is known about the contribution of diagnostic error to maternal morbidity

244. Why Is Improving Diagnosis Important? Physician and Patient Perspectives (pdf file)
     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

245. Mod01-Grand-Rounds-Slides (pdf file)
     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.

246. Apply Module Slide Presentation Text Descriptions | Agency for Healthcare Research and Quality
     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.

247. PowerPoint Presentation
     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.

248. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2021.xlsx
     January 01, 2021 - The tables include the relative frequencies by type of device, by device defect, failure or use error … Total Unknown 57.0% 14,500 25,418 Device defect or failure, including HIT 30.0% 7,617 25,418 Use error … 9.2% 2,348 25,418 Combination or interaction of device defect or failure and use error 3.7% 953 25,418 … defect or failure, including HIT 41.3% 839 35.3% 147 2,447 Unknown 27.4% 557 24.8% 103 2,447 Use error … 24.1% 489 29.1% 121 2,447 Combination or interaction of device defect or failure and use error 7.2%

249. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions7.html
     June 01, 2023 - Engineering, and Medicine, Institute of Medicine, Board on Health Care Services, Committee on Diagnostic Error … Defining, identifying, and measuring error in emergency medicine. … Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological … Cognitive bias impact on management of postoperative complications, medical error, and standard of care … Cognitive interventions to reduce diagnostic error: a narrative review.

250. Challenges to Real-Time Decision Support in Health Care (pdf file)
     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.

251. Factors That Influence Effectiveness of Checklists | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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

252. 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

253. Cuestionario sobre la seguridad de los pacientes en las farmacias en su comunidad (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/pharmacy/toolkit/pharmform_span.doc
     May 05, 2014 - ► Un error es cualquier tipo de equivocación o error en el medicamento, o cualquier incidente relacionado … Cuando ocurre un error, tratamos de averiguar los problemas en los procesos que dieron lugar al error … Cuando el paciente recibe un medicamento con algún error que podría causarle daño al paciente pero no … Cuando el paciente recibe un medicamento con algún error que no tiene la posibilidad de causar daño, … Cuando un error que podría haber causado daño al paciente se corrige ANTES de que el medicamento salga

254. 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

255. Final Progress Report: MOVES: Patient-Based Strategy To Reduce Errors in Diabetes Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/oconnor-report.pdf
     January 01, 2024 - It also appears that a given physician makes the same error recurrently. … error is the main dependent variable of interest for Hypothesis 1. … However, it is important to recall that, among all patients with an error of commission or an error … rates, other error reduction strategies may significantly reduce error rates. … Analyses for each error included patients with specified errors pre-intervention.

256. 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.

257. 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?

258. 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

259. 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.

260. Final Progress Report: Real-time assessment of risk factors for medication errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/dresselhaus-report.pdf
     January 01, 2024 - During sampled intervals, 151 error reports were obtained involving 56 (29 physicians and 27 nurses) … Medical error has become a prominent concern since the Institute of Medicine (IOM) published To Err … In such cases, we will approximate error events to self-report ratings by aggregating across larger … However, they do permit some level of interpretive analysis, even with incomplete error data points. … During sampled intervals, 151 error reports were obtained involving 56 (29 physicians and 27 nurses)