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301. 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

302. 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.

303. 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.

304. 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.

305. 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.

306. 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

307. 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

308. 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.

309. Cognitive Load Theory and Its Impact on Diagnostic Accuracy: Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load-theory.pdf
     May 01, 2024 - the Institute of Medicine in 1999, was one of the first publications to bring the issue of medical error … In addition, diagnostic error may result in serious harm to more than 500,000 Americans each year across … often takes place after the error has occurred. … Burden of serious harms from diagnostic error in the USA. … Diagnostic error in internal medicine.

310. 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

311. 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

312. 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.

313. 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

314. The Use of Surgical Simulators to Reduce Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Fried.pdf
     January 01, 2003 - Error reduction and surgical expertise can be achieved through the implementation of a dynamic, simulation-based … Errors in ESS were identified, and each error was classified according to a taxonomy of error types … Quantifiable measures then were defined for each error. … This rigorous process has brought to the project an added emphasis on error reduction prevention as … uniform and comprehensive manner precisely what the errors are and how to avoid them.23 The key to error

315. Appendix A. SIDM Competencies To Improve Diagnosis and Suggested Questions for Debriefing Case Studies | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html
     September 01, 2022 - and understand the systems factors that facilitate and contribute to timely, accurate diagnoses and error … Discuss how human factors contribute to diagnostic safety and error by identifying how the work environment … What are some reasons an error could occur related to your work environment? … How and to whom would you report this error [or missed opportunity]?

316. Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hannah_23.pdf
     February 24, 2008 - • Nonpunitive response to error. … • Feedback & communication about error. … Error in medicine. JAMA 1994; 272: 1851-1857. 5. Leape LL. Preventing adverse drug events. … Promoting patient safety by preventing medical error. JAMA 1998; 280: 1444-1447. 11. … Error, stress, and teamwork in medicine and aviation: Cross sectional surveys.

317. Final Progress Report: Systems Approach for Improving Region-Wide Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
     January 01, 2024 - Error reduction in organizations involves exploration and evaluation of multiple interrelated systems … Adverse Drug Events (ADEs), which can result from a medication error, occur at a rate of 2.4% to 4.6% … The purpose of MedMARx is to allow hospitals to report, track, and share medication error data in a … on Medication Error Reporting and Prevention (NCCMERP). … Perceived Barriers in Using a Region-Wide Medication Error Reporting System.

318. TeamSTEPPS for Diagnosis Improvement: Knowledge Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dxsafety-knowledge-assessment.pdf
     February 01, 2022 - TeamSTEPPS To Improve Diagnosis uses the National Academy of Medicine definition of diagnostic error … Using this definition, which of the following may be considered a diagnostic error? a. … Causes of diagnostic error may include: a. Poor clinical reasoning. b. … Diagnostic error is: a. Common, harmful. b. Costly and often preventable. c. … Is a tool designed for individuals who have made a diagnostic error. a.

319. Clinical Inertia and Outpatient Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
     January 01, 2003 - Subsequent actions are also in error, since knowledge of appropriate thresholds fails to cover future … Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Error /CompatibilityLevel

320. Facilitator-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module1/facilitator-notes.docx
     March 01, 2017 - Can you identify examples of human error in your unit or facility? … SLIDE 18 SAY: To improve outcomes, human error, at-risk behavior, and reckless behavior should each … · 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