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261. 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

262. 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

263. 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.

264. MEASUREMENT OF DIAGNOSTIC ERRORS IS THE FIRST STEP TO IMPROVEMENT (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/singh-summit2016.pdf
     September 01, 2016 - diagnosis”  lack of standards for most “diagnosis” concepts  Operational definitions of diagnostic error … missed opportunities that warrant additional clinical evaluation  Stronger signals to bolster error … 2011Singh et al JAMA IM 2012; Singh and Sittig BMJQS 2015; Singh et al Peds 2010 Approach Diagnostic “Error … Progress Safer Dx Measurement Framework Time Ripe for Retrospective Measurements Approach Diagnostic “Error

265. 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

266. Resources Related to Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/index.html
     March 01, 2025 - Issue Briefs Journal Articles Diagnostic error in mental health: a review .  … Defining diagnostic error: a scoping review to assess the impact of the national academies' report improving … You can search diagnostic error to find related studies and resources.

267. 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

268. Methodological Challenges in Describing Medication Dosing Errors in Children (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
     January 01, 2004 - medication errors that occur, the clinical importance of these errors, or effective strategies for error … This would provide a conservative estimate of medication dosing error rates. … Therefore, it is difficult for pharmacies to correctly determine if a weight-based dosing error has … Medication error prevention by clinical pharmacists in two children’s hospitals. … The impact of computerized physician order entry on medication error prevention.

269. 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

270. Final Progress Report: Application of Machine Learning to Enhance e-Triggers to Detect and Learn from Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/singh-report.pdf
     January 01, 2025 - Key Words: Diagnostic error, machine learning 2. … Test Hypothesis 2 (supervised ML improves performance of diagnostic error e-triggers): a. … Development of a Machine Learning Enhanced Trigger to Detect Diagnostic Error [abstract]. … Emergency medicine: a practice prone to error?. … The incidence of diagnostic error in medicine.

271. Final Progress Report: Real-time assessment of risk factors for medication errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14283-Dresselhaus-draft-1.pdf
     September 29, 2005 - 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)

272. SOPS State Hospital Association Webcast - Bakdash Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-sops-hospital-survey-workplace-item-set-webcast-bakdash.pdf
     December 01, 2024 - and Work Pace (4 items) • Organizational learning – Continuous Improvement (3 items) • Response to Error … • Supervisor, Manager or Clinical Leader Support for Patient Safety (3 items) • Communication About Error … Communication About Error Your Hospital 73% 1%Data Base … Response to Error Your Hospital 63% -1%Data Base 64%

273. Final Progress Report: Blood Product Transfusion & Safe Practices (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/herwaldt-report.pdf
     January 01, 2024 - This function tracks Error Flag, PID, Sample ID, Requisition ID, Order Card ID, date/time, Error Message … Correct error before proceeding NoAllscans match? … Correct error before proceeding Correct error before proceeding Complete tests, type/screen as ordered … Correct error before proceeding Step 4. … Prevented Error = Mismatch between two different, valid Patient IDs Skipped Step = An upstream scan

274. 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

275. 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

276. 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

277. 20 Tips To Help Prevent Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/care-planning/errors/20tips/20tips.pdf
     September 01, 2011 - To Help Prevent Medical Errors One in seven Medicare patients in hospitals experience a medical error

278. 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?

279. 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.

280. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
     March 01, 2020 - intended to answer one primary question, “What PSPs can assist in decreasing patient identification error … Site" OR "Medical Mistake*" OR "Disclosure of Error*" OR "Mental Error*" OR "Action Error*"))) … Patient Surger*" OR "Wrong- Patient Surger*" OR "Wrong Procedure Error*" OR "Wrong- Procedure Error … *" OR "Mental Error*" OR "Action Error*") AND ((MH "Operating Rooms") OR (AB "Operating Room … Patient Identification Error in the Operating Room Search Terms