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261. Diagnostic Stewardship in Action | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship6.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 … mismanagement of a correctly diagnosed patient, such incidents could also result from a diagnostic error … To the extent that diagnostic error contributes to inappropriate use of transfusion, diagnostic stewardship

262. Learn-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-facilitator-guide.docx
     May 01, 2017 - Can you identify examples of human error in your unit or hospital? … Slide 15 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

263. Clarification in Using Different Paradigms and Terms for Improvement Efforts | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology6.html
     April 01, 2025 - standards used to assess care established a priori, before an event, or was something declared to be “an error … How were judgments of “error” and preventability determined?

264. Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
     January 01, 2024 - Scope Institute of Medicine (2004) reports on patient safety and medical error have led to an emphasis … Research suggests at least 10% of administered doses of medication result in error (Barker & Allan, … health information technology (HIT) to support the delivery of medication, enhanced adverse event and error … workarounds can lead to medical errors, there has been little attempt to examine changes in risk of error … On the other hand, workarounds of these blocks may make the system vulnerable to error and increase

265. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patient-role-references.html
     September 01, 2024 - Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; National … Burden of serious harms from diagnostic error in the USA. … The patient is in: patient involvement strategies for diagnostic error mitigation. … Diagnostic error experiences of patients and families with limited English-language health literacy or … Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; National

266. On-line Patient Safety Climate Survey: Tool Development and Lessons Learned (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Connelly.pdf
     January 01, 2003 - New safety and error reduction standards for hospitals. … Error in medicine. JAMA 1994;272:1851–7. 7. Leape LL, Simon R, Kizer WK, et al. … Reducing medical error: can you be as safe in a hospital as you are in a jet? … Error, stress, and teamwork in medicine and aviation: cross sectional surveys. … Improving quality, minimizing error: making it happen. Health Aff 2001;20(3):68–81. 16.

267. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - patient safety"[All Fields] OR "safety culture"[All Fields] OR "systems approach"[All Fields] OR "medical error … Fields] OR "medical mistake*"[All Fields] OR "adverse event*"[All Fields] OR checklist ((medical error … surveillance [mh] OR safety [mh] OR (adverse [ti] AND (drug* [ti] OR event* [ti])) OR (medication* [ti] AND (error

268. Final Report: Improving Drug Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/magid-report.pdf
     January 01, 2024 - Key Words: Medication safety, pharmacy, decision support, alert systems, error reduction Improving … Although the methodological quality of the research is variable, error reduction strategies with some … Improving Drug Safety 1 UC1 HS14249 9 Most medication error reduction strategies have focused … If PIMS detected a possible error in lab monitoring, then a medication alert was issued, but, unlike … First, most medication error prevention programs have been studied in the inpatient setting.

269. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-references.html
     June 01, 2023 - Families as partners in hospital error and adverse event surveillance. … The patient is in: patient involvement strategies for diagnostic error mitigation. … Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. … Patients’ perspectives of diagnostic error: a qualitative study. … The Public’s Views on Medical Error in Massachusetts.

270. Final Progress Report: Ambulatory Pediatric Patient Safety Learning Lab: Pursuing Safe Healthcare at Home (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/walsh-kirkendall-report.pdf
     January 01, 2025 - Inter-rater reliability for error occurrence was 100%. 2,35,36 Inter-rater reliability for error occurrence … We summarized demographics and error rates using descriptive statistics. … The most common error participants made was management of ketones (Table 3). … Type and Frequency of Errors in Simulated Sick Day Scenarios Error type # with error Insulin dosing … error, n (%) 3 (25) Technology error, n (%) 2 (17) Ketone management error, n (%) 5 (42) Treatment

271. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
     January 25, 2008 - Medication error B. Adverse drug reaction (not a medication error) C. … Error related to procedure, treatment, and/or test F. … Distinguishing acute from chronic conditions—diagnoses with a single opportunity for error vs. … diagnoses with multiple opportunities for error—can be useful. … Medical Care Availability and Reduction of Error (MCARE) Act.

272. University of Pittsburgh Uses AHRQ's Patient Safety Culture Survey to Help Improve Nursing Home Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0702.html
     October 01, 2014 - to the AHRQ survey when I was preparing to launch a survey to understand the barriers to medication error … patient safety culture data in nursing homes before we implemented a new system to increase medication error … These significant differences were reported in nonpunitive response to error, teamwork within units,

273. Module 1: Using the Comprehensive Long-Term Care Safety Modules: Applying Safety Principles: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module1/mod1-facguide.html
     March 01, 2017 - Can you identify examples of human error in your unit or facility? … Slide 19: Managing Error and Risk 1 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 team members who have committed a human error and to ensure

274. Just Culture Webcast November 2016 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-transcript-508-compliant.pdf
     June 01, 2017 - to feature Celeste Mayer, who will talk about her experiences improving the Nonpunitive Response to Error … for this webinar, Nonpunitive Response to Error. … So, what is Nonpunitive Response to Error? What does it really consist of? … to what we call Response to Error, to include more Just Culture principles in the survey items. … There is a section for Nonpunitive Response to Error.

275. (“Apply CUSP” cover slide with CUSP Toolkit logo)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/apply/applycusp.pptx
     August 18, 2011 - staff members who hold themselves accountable 5 5 6 Understanding Risk and Human Behavior1 Human Error … Behavior: Choosing to consciously disregard a substantial and unjustifiable risk 6 Managing Error … and Risk1 7 Human Error Product of our current system design and behavioral choices Manage through changes … communication Identify barriers to communication Describe the connections between communication and medical error

276. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship2.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

277. Diagnostic Safety Issue Brief 21 Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/dx-safety-21-diagnostic-stewardship.pdf
     August 01, 2024 - improve diagnostic testing should target breakdowns in the testing process that lead to diagnostic error … 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. … Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine;

278. Final Progress Report: Center for Safety In Emergency Care (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/wears2-report.pdf
     January 01, 2025 - New Technology and Human Error. Chichester, UK: Wiley; 1987:276 - 83. … Human Error: Cause, Prediction, and Reduction. … The Field Guide to Human Error Investigations. Aldershot, UK: Ashgate; 2002. … Profiles in patient safety: sidedness error. Acad Emerg Med 2002;9(4):326-9. … Profiles in patient safety: authority gradients in medical error.

279. Background | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship3.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

280. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-5.html
     June 01, 2020 - Reducing Diagnostic Error: Measurement Considerations. October 2019. … Diagnostic Error Change Package. … The next organizational challenge: finding and addressing diagnostic error. … Minimizing diagnostic error: the importance of follow-up and feedback. … Diagnostic error in medicine: analysis of 583 physician-reported errors.