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301. 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]?

302. 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.

303. 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.

304. 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.

305. 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.

306. 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

307. Final Progress Report: Workshop on Consumer Engagement in Selected Patient Safety Topics (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/hatlie-report.pdf
     January 01, 2024 - Effectively responding when error occurs, and engaging patients in organizational learning from such … Prioritizing error prevention initiatives in Chicago; and 6. … Key Words: Action Planning; Communication; Disclosure; Error prevention; Patient Engagement; Patient … Safety; Patient Reporting of Error ***** I. … Prioritizing error prevention initiatives in Chicago; and 6.

308. 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

309. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
     January 01, 2024 - With this increased complexity comes an increased risk of error and potential harm. … Error did not reach the patient. Very slight on subsequent process activity. … Page 7 3 Slight effect Error reached the patient. Patient is not harmed. … Error reached the patient. Slight effect on the patient, but patient is unharmed. … Page 8 8 Extreme effect/major injury Actual error occurred and reached the patient.

310. Common Cause Analysis: Focus on Institutional Change (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
     January 20, 2008 - and assigning blame to the error. … Error detectability can also relate to a process. … Medical care availability and reduction of error (MCARE) Act; March 20, 2002. … Error in medicine. JAMA 1994; 272: 1851-1857. 10. Nolan TW. … Michael Cohen on medication error reporting and patient safety.

311. 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

312. Table 1. Overview of studies on the effectiveness of checklists | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxchecklists-table1.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Table 1. … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error

313. Success Stories from the AHRQ Medical Office Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/mowebinar_2014/stroud-0914slides.pdf
     January 01, 2014 - 2013 Pe rc en t P os iti ve R es po ns e Year Administered 36 36 Communication About Error … patient safety concerns 41 41 Strategies Implemented • Good Catches  A "Good Catch" is an error … Toolkit Material- Example Sharing Results Utilizing Survey Data Teamwork Communication About Error

314. Issue Brief 7. Improving Education: A Key to Better Diagnostic Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/dxsafety-issuebrief-education.pdf
     March 11, 2022 - Diagnostic error in internal medicine. … Cognitive interventions to reduce diagnostic error: a narrative review. … Overconfidence as a cause of diagnostic error in medicine. … Clinical reasoning and diagnostic error: a call to merge two worlds. … Nurses, diagnosis, and diagnostic error.

315. Catheter Care and Maintenance Quiz | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/quiz.html
     March 01, 2017 - Determine the catheter care error. … Determine the catheter care error.

316. Patient Safety Research in Medical Group Practices: Measurement and Data Challenges (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
     December 01, 2004 - found that 13.5 percent of the prescriptions written for a managed care population resulted in an error … An error may or may not result in an adverse event, which is an instance of a patient suffering the … consequences of an error. … Epidemiology of medical error. [See Comment.] BMJ 2000 Mar 18;320(7237):774–7. 4. … Medical error: what do we know? what do we do? San Francisco: Jossey-Bass; 2002. p. 325. 39.

317. Final Progress Report: Improved Patient Safety Through Web-Based Education (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/hendee-report.pdf
     January 01, 2024 - Healthcare Errors, Hospital Safety, Safety Education, Patient Information, Healthcare Quality, Medication Error … , Medical Error Purpose: Develop, evaluate, and disseminate web-based, population-specific education … Learning from Mistakes • Disclosure of Injuries and Errors • Retrospective Analysis • Technologies for Error … and the Culture • Breaking Down Barriers • Impact of a Close-Call Reporting System • Learning from Error … • Reporting Error and Follow Up • The Proactive Approach to Error • Health Literacy • Technology

318. Final report: To Quantify the Impact of the Existing vs. Enhanced Work Configuration of Radiation Therapy Technicians on Workload, Situation Awareness, and Performance during Pretreatment QA Tasks (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/mosaly-report.pdf
     January 01, 2024 - Table 1: Description of simulated scenarios and corresponding embedded error in each scenario Scenario … Description Embedded Error 1. … The error detection and procedural compliance was calculated as the average score of error detection … and/or missing information, 1 denotes proper documentation of error and/or missing information). … An alpha of 0.05 was used for an acceptable type-I error for statistical significance.

319. Appendixes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-appendix.html
     November 01, 2017 - adverse drug reaction"[tiab] OR "adverse drug reactions"[tiab] OR "medication errors"[mh] OR "medication error … Mean Attributable Cost Calculated $6,721.00 $786.00 $5,483.00         Standard Error … Y Year of Cost Data 2007 Mean Attributable Cost Calculated $3,936.00 Standard Error … Year of Cost Data       Mean Attributable Cost Calculated       Standard Error … 1991 l 2009 Mean Attributable Cost Calculated $2,247 $3,802 $13,806 Standard Error

320. Interplay Between Cognitive Load and Diagnostic Accuracy | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
     May 01, 2024 - errors. 25,26 In one study, radiology residents had a 12 percent increased likelihood of a diagnostic error … It may make intuitive sense that more rapid and frequently heuristic cognition is more error prone. … this example, the presence of overwhelming extrinsic load and cognitive overload leads to a diagnostic error … This error results in a missed diagnosis and lack of treatment for pneumonia, which can progress to more