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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.
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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.
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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].
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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.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/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
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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
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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
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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.
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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
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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
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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
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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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - 361 facilities submitted 8,862
records (4.1 percent) citing the dispensing device as the cause of error … A medication error was defined using the
National Coordinating Council for Medication
Error Reporting … The lorazepam administration error did not result in an adverse event for the
patient, since the allergy … Automated medication dispensing
systems: Not error free. J Emerg Nurs 2006; 32:
71-74.
4. … National Coordinating
Council for Medication Error Reporting and
Prevention; 2005 December.
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www.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
March 01, 2024 - Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating … 23 percent of patients treated at 29 academic medical centers in the U.S. experienced a diagnostic error … by Agency-funded research teams that have published essential insights into areas such as diagnostic error
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html
June 01, 2023 - Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute … Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. … Families as partners in hospital error and adverse event surveillance. … The Public’s Views on Medical Error in Massachusetts. … Patients’ perspectives of diagnostic error: a qualitative study.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/facapplycusp.docx
June 02, 2025 - · Can you identify examples of human error in your unit or hospital? … Slide 6
SAY:
To improve outcomes, human error, at-risk behavior, and reckless behavior each should … 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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keyes.pdf
January 01, 2004 - Woolf, Characterizing
Medical Error: A Primary Care Study).
2. … Thomas,
Teamwork and Error in Neonatal Intensive Care). … Federal Government
had ever made to combat medical error. … For example, five grants
address the epidemiology of error as a principal goal. … Error, stress,
and teamwork in medicine and aviation: cross
sectional surveys.
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-1.html
September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction
Introduction … Next Page
Table of Contents
Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship-references.html
August 01, 2024 - as a Model To Improve the Quality and Safety of Diagnosis
Introduction
Background
Diagnostic Error … in the Testing Process
Diagnostic Stewardship Interventions To Reduce Diagnostic Error
Diagnostic … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Analysis of diagnostic error cases among Japanese residents using diagnosis error evaluation and research … Diagnostic stewardship to prevent diagnostic 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-Jones_29.pdf
February 23, 2008 - Results: Implementing a systematic
voluntary medication error reporting program supported by specific … , and phase of the medication use system in which the error
originated. … , nonpunitive response to error, and staffing. … We used a Bonferroni correction (P = 0.05/5 = 0.01) to
control the Type 1 error rate due to the five … MEDMARX® National Medication Error Database
(database online). United States Pharmacopeia.