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281. 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

282. 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

283. 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.

284. 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.

285. 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.

286. 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.

287. Spanish Community Pharmacy Survey on Patient Safety Culture Items and Dimensions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/measures-spanish.pdf
     April 01, 2014 - Cuando ocurre un error, tratamos de averiguar los problemas en los procesos que dieron lugar al error … Cuando un error sigue ocurriendo, cambiamos la manera en que se trabaja. C10. … Cuando el paciente recibe un medicamento con algún error que podría causarle daño al paciente pero no … Cuando el paciente recibe un medicamento con algún error que no tiene la posibilidad de causar daño, … Cuando un error que podría haber causado daño al paciente se corrige ANTES de que el medicamento salga

288. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
     March 26, 2008 - considered preventable.2 Administration is the stage of the medication use process most vulnerable to error … Critical care studies in high-alert IV medication administration found error rates of 34 percent14, … Look-alike and work-alike drugs and drugs with sound-alike names all increase the possibility of error … CPOE systems do not address this type of error,4 and bedside barcode scanning alone is not sufficient … ISMP medication error report analysis. Hosp Pharm 2005; 40: 210-12. 32.

289. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
     July 18, 2008 - tools, strategies, behaviors, and principles can be implemented as countermeasures to elements of the error … Ambulatory Care Setting Patients and health care providers have become increasingly aware of medical error … Further analysis revealed judgment error (79 percent), failure of vigilance or memory (59 percent), … chain.9 A literature review and collaborative project,10 “diagnosing diagnosis error,” formulated … , and mitigation of medical error and help tocreate a safer environment for patients and families.

290. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - Slide 4 Active Failures SAY: Active failures occur because of human error. … Though the resident can still receive the wrong medication due to human error, or active failures, we … It could also be due to human error, or “active failure”— the long-term care clinician did not count … A simple clerical error is another possible human error. Slide 13 Why Did It Happen? … Imagine what changes you can make to the system which may protect against human error.

291. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science-brief1.pdf
     April 02, 2020 - Reducing Diagnostic Error: Measurement Considerations. … The challenges in defining and measuring diagnostic error. … The incidence of diagnostic error in medicine. … Minimizing diagnostic error: the importance of follow-up and feedback. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

292. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
     April 02, 2020 - Reducing Diagnostic Error: Measurement Considerations. … The challenges in defining and measuring diagnostic error. … The incidence of diagnostic error in medicine. … Minimizing diagnostic error: the importance of follow-up and feedback. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

293. Windows of Opportunity | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence6.html
     April 01, 2025 - institutions to fulfill the NASEM report’s recommendations to create reporting systems for diagnostic error … For example, stories of a medical error that led a young boy to die of sepsis prompted multiple statewide … improvement was profoundly impacted when a physician within their own organization experienced a medication error

294. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
     September 28, 2016 - . • Develop a knowledge base for learning about errors' causes and effective error prevention. … Diagnostic Error: Magnitude of the Problem • 12 million or 5 % U.S. adults seeking outpatient care … each year experience a diagnostic error. … • Evaluate diagnostic error as a quality of care challenge • Examine the epidemiology, burden of … Slide Number 50 Slide Number 51 Slide Number 52 Diagnostic Error: �Magnitude of the Problem Study

295. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
     January 01, 2025 - We explored the variable definitions of error; individual and organizational variability in decision … Key Words: medication delivery, decision making, human factors, error, harm, safety, systems PURPOSE … The goal of the Operating Room Systems based Medication Administration error Reduction Team (OR SMART … A medication error can be described as “any error involving the prescribing, ordering, selection, or … A medication error in the perioperative setting is three times more likely to result in harm that in

296. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 -  To assess the impact of stimulated reporting on reported error/adverse event rates. … Scope: Background: Error Reporting Systems, and Learning from Error Although iatrogenic injury causes … The goals will be to refine error detection and classification schemes so that reports can be used by … However, there was no impact on the serious medication error rate or the preventable ADE rate. … may be defined as the defect in the system that permitted such an error to occur.

297. Gap Analysis Facilitator's Guide: Appendix E | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.html
     August 01, 2022 - While restitution for patients and families affected by medical error is essential, the standard process … frustration and anger for patients and can diminish the opportunity for hospitals to learn and improve from error

298. Module 2: Obtaining Organizational Buy-in and Support | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes2.html
     August 01, 2022 - Slide 9 Say: To improve outcomes, human error, at-risk behavior, and reckless behavior … 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 … Forcing functions, checks, and redundancies are some features of systems intended to minimize the risk of error

299. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
     June 15, 2003 - limitations of current reporting systems and realities constraining their use inhibit widespread error … Safety infrastructure Error reporting systems and associated information sharing and problem- solving … , ongoing quality improvement programs, and internal reporting systems for complying with multiple error … Some hospitals also keep separate, customized medication error databases, while other hospitals use … Finally, there is a high degree of informal error reporting that is not captured by any system.

300. Diagnostic Safety Issue Briefs | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs.html
     July 01, 2025 - Safety Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Education—A Key to Better Diagnostic Outcomes Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error