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281. The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Galt.pdf
     January 01, 2005 - prescribing [e- prescribing], or both) that was responsible for influencing the error. … Potential impact of PDA application on type of prescribing error Provides opportunity to reduce error … This improves our ability to understand and compare data from error studies. … Fundamentals of medication error research. Am J Hosp Pharm 1990;47:555–71. 34. … Potential impact of PDA application on type of prescribing error Table 2.

282. Producing Accurate Clinical Quality Reports for Population Health: A Delivery System-Oriented Approach to Report Validation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/ehr-reports.pdf
     March 01, 2016 - .........14 Case Study..............................................................14 Sources of Error … ....15 Inclusion Errors ............................................................16 Inclusion Error … One by one, the Medical Director and her DBA figured out and corrected the cause of each error. … Once an error is found, it is important to document the information both by the nature of the error … Inclusion Error Examples 1.

283. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072320.pdf
     November 06, 2020 - • PSNet: Published a primer on 7/22/20 called COVID-19 and Dx Error. … grant=R01+HS27614-01 https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error … https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error https://www.cdc.gov … • Recently Published Diagnostic Safety Relevant Papers: o Reducing the Risk of Diagnostic Error in … www.journalofhospitalmedicine.com/jhospmed/article/222266/hospital-medicine/reducing-risk-diagnostic-error-covid

284. Laying the Groundwork to Improve Diagnosis in Health Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-graber.html
     May 01, 2020 - Graber received AHRQ grant funding to establish the "Diagnostic Error in Medicine" conference, which … researchers and clinicians focus on issues at the intersection of diagnostic reasoning and medical error … The report concluded that most people will experience at least one diagnostic error in their lifetime

285. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/liability/brock.html
     August 01, 2017 - and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Error … Interventions to improve skills around error disclosure constitute a good test of the OCS; successful … Training involved a mix of didactic and error disclosure simulation. … Error disclosure: A new domain for safety culture assessment. … Implementing an error disclosure coaching model: a multicenter case study.

286. Christiana Care Health System: Safety Mentor Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell_94.pdf
     March 30, 2008 - A staff survey in 2001 showed that there were opportunities for improvement related to error reporting … Staff across the board felt they had responsibility for error prevention but viewed the error-reporting … Survey respondents also expressed fear of the consequences of being associated with an error. … However, the best technology alone will not eradicate error. … Only 55 percent of respondents felt that error reporting was widely encouraged and nonpunitive.

287. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/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?

288. Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/apply/ac-cusp.html
     December 01, 2012 - Managing Error and Risk Slide 8. … Can you identify examples of human error in your unit or hospital? … Managing Error and Risk   Say: To improve outcomes, human error, at-risk behavior, and reckless … Human error is a product of both system design and behavioral choices. … Describe the connections between communication and medical error.

289. Final Progress Report: Leveraging Existing Assessments of Risk Now (LEARN) Final Report (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
     January 01, 2025 - Risk Assessment C.5.a Error Science and Medicine The study of error and safety in the 20th century … If info is wrong, the Fenwal armband on patient will catch the error. … risk of error in the care of a pediatric patient. … Human Error. Cambridge University Press: New York, 1990. 7 Norman D. … Promoting Patient Safety and Preventing Medical Error in Emergency Departments.

290. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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

291. Introduction | Agency for Healthcare Research and Quality
     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

292. Introduction | Agency for Healthcare Research and Quality
     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

293. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/education-dx-outcomes-7.html
     March 01, 2022 - Diagnostic error in internal medicine . Arch Intern Med. 2005;165(13):1493-9. … Diagnostic error in medicine—analysis of 583 physician-reported errors . … Cognitive interventions to reduce diagnostic error: a narrative review . … The patient is in: patient involvement strategies for diagnostic error mitigation . … Nurses, diagnosis, and diagnostic error . Diagnosis (Berl). 2017;4(4):197-9.

294. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-7.html
     March 01, 2022 - Diagnostic error in internal medicine . Arch Intern Med. 2005;165(13):1493-9. … Diagnostic error in medicine—analysis of 583 physician-reported errors . … Cognitive interventions to reduce diagnostic error: a narrative review . … The patient is in: patient involvement strategies for diagnostic error mitigation . … Nurses, diagnosis, and diagnostic error . Diagnosis (Berl). 2017;4(4):197-9.

295. Learn About the Comprehensive Unit-based Safety Program for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/perinatal-care/modules/teamwork/learn-about-cusp-fac-guide.html
     May 01, 2017 - 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

296. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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].

297. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
     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].

298. Current State of Diagnosis Education | Agency for Healthcare Research and Quality
     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

299. Understanding SOPS Surveys: A Primer for New Users (Webcast) - Gray (Overview) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-SOPS_101_Webcast-GRAY-Overview.pdf
     March 03, 2020 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management … in medical offices supports accurate diagnoses ► Assist in identifying processes and sources of error

300. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
     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.