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281. 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.

282. AHRQ Research Summit on Improving Diagnosis in Health Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety.html
     April 01, 2019 - Quality 5600 Fishers Lane Rockville, MD 20857 Most patients will experience at least one diagnostic error … chapters, aligning with the breakout sessions: Data and Measurement— Chapter 3: Overview of Diagnostic Error

283. 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.

284. 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,

285. 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

286. 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.

287. (“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

288. 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

289. 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;

290. 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.

291. 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.

292. 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

293. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology-references.html
     April 01, 2025 - Human Error . Cambridge, UK: Cambridge University Press; 1990. … Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-770. PMCID: PMC1117770. … Patterns of error in interpretive pathology. Am J Clin Pathol 2022 May 4;157(5):767-773. … https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1 … https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2

294. TeamSTEPPS 3.0 | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/index.html
     Diagnosis Improvement and how the TeamSTEPPS framework can be applied to the specific problem of diagnostic error … Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error

295. Learn About the Comprehensive Unit-Based Safety Program for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-about-cusp-facilitator-guide.pdf
     May 01, 2017 - • Can you identify examples of human error in your unit or hospital? … SAY: To improve outcomes, human error, at-risk behavior, and reckless behavior each should be managed … 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

296. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
     August 01, 2022 - occurring in 5 percent of ED visits translates to about 7 million cases of ED-based diagnostic error … What interventions could reduce diagnostic error in emergency departments? … inform diagnosis and error. … Interdisciplinary communication: an uncharted source of medical error? … Diagnostic error in medicine: analysis of 583 physician-reported errors.

297. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
     August 01, 2022 - occurring in 5 percent of ED visits translates to about 7 million cases of ED-based diagnostic error … What interventions could reduce diagnostic error in emergency departments? … inform diagnosis and error. … Interdisciplinary communication: an uncharted source of medical error? … Diagnostic error in medicine: analysis of 583 physician-reported errors.

298. Research Summit: Improving Diagnosis in Health Care: Agenda | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety-agenda.html
     August 01, 2017 - MM/MBA Stanford University Breakout 1 (morning): Use of Data and Measurement in Reducing Error … MM/MBA Stanford University Breakout 2 (afternoon): Use of Data and Measurement in Reducing Error … Lucy Savitz, PhD, MBA Intermountain Healthcare Helen Haskell, MA Mothers Against Medical Error

299. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.html
     June 01, 2023 - They did not acknowledge that I had really been sick due to their error in diagnosis and never had to … Types and prevalence of patient/family-reported diagnostic errors Type of Diagnostic Error … Concerns by Aspects of Diagnosis Empowered Patient Coalition Survey 19 (n=184) Medical Error … columns total more than 100 percent because narratives often identify multiple forms of diagnostic error … The Medical Error Recontact Survey percentages were calculated by the authors from unpublished data.

300. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
     January 01, 2007 - Introduction Although the extent of medical error has been well characterized among general medicine … Since physicians are doing the reporting, this would mean less opportunity for them to notice an error … Second, the level of clinical responsibilities and the corresponding available time to devote to error … Finding and fixing medical error: Opportunities for clinicians. … Error in medicine. JAMA 1994; 272: 1851-1857. 12 Chaudhry SI, Olofinboba KA, Krumholz HM.