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301. 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].

302. 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.

303. TeamSTEPPS 3.0 | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/index.html
     November 01, 2024 - 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

304. Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
     April 30, 2022 - Category: Delta (% Positive - % Negative) Scores Slope: Pattern Communication Response to Error … IP O VE R AL L Key takeaways: Positive:  Report, communication, learning and response to error … 2024 SOPS Survey -- 323 responses 36 v Communication 323 72% 19% 9% 73% 64% | 9% > Response to error … 318 68% 19% 13% 68% 60% | 8% > Communication about error 310 74% 21% 5% 74% 70% | 4% > Communication … 1.9-2.2) 40 TENTS vs Patient Safety Survey (Communication; 1 unit data only) Communication about error

305. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - A Heparin Error Reduction Workgroup (HERW)—consisting of staff nurses, pharmacists, and a cardiologist—was … The analysis also identified several sources of potential error, particularly in situations in which … The potential sources of error and recommended actions are discussed in the following subsections of … Potential sources of error Confusing protocol selection. … A Heparin Error Reduction Workgroup was convened to address the issue.

306. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
     March 01, 2024 - Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating … 23 percent of patients treated at 29 academic medical centers in the U.S. experienced a diagnostic error … by Agency-funded research teams that have published essential insights into areas such as diagnostic error

307. The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-patient-role.pdf
     September 01, 2024 - independent national advocate for patients and families Helen Haskell, M.S., Mothers Against Medical Error … Patients and caregivers who have experienced a diagnostic error can provide a unique perspective. … Goals for Improving Diagnosis and Reducing Diagnostic Error • Facilitate more effective teamwork in … Burden of serious harms from diagnostic error in the USA. … The patient is in: patient involvement strategies for diagnostic error mitigation.

308. The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/dx-safety-issue-brief-co-design-rev.pdf
     September 01, 2024 - independent national advocate for patients and families Helen Haskell, M.S., Mothers Against Medical Error … Patients and caregivers who have experienced a diagnostic error can provide a unique perspective. … Goals for Improving Diagnosis and Reducing Diagnostic Error • Facilitate more effective teamwork in … Burden of serious harms from diagnostic error in the USA. … The patient is in: patient involvement strategies for diagnostic error mitigation.

309. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
     July 01, 2022 - Diagnostic error in internal medicine. … What factors prompted the error discovery? … No Harm � Category A- Circumstances or events that have the capacity to cause error Error, No Harm … � Category B- An error occurred but the error did not reach the patient (An “error of omission” does … occurred that required intervention necessary to sustain life Error, Death � Category I- An error occurred

310. Intro (pdf file)
     www.ahrq.gov/downloads/monahrq/pdf/MONAHRQ_v3_ReleaseNotes.pdf
     June 01, 2012 - ................................................ 8 5.1 AHRQ Quality Indicators Prediction Module Error … During Data Load .................................................... 8 5.2 APR Grouper Error During … ................................................................................ 9 5.3 “Ordinal” Error … The most common are explained below. 5.1 AHRQ Quality Indicators Prediction Module Error During … id=14431. 5.3 “Ordinal” Error Message during Run Analysis Problem: During the Run Analysis

311. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
     March 12, 2008 - 361 facilities submitted 8,862 records (4.1 percent) citing the dispensing device as the cause of error … A medication error was defined using the National Coordinating Council for Medication Error Reporting … The lorazepam administration error did not result in an adverse event for the patient, since the allergy … Automated medication dispensing systems: Not error free. J Emerg Nurs 2006; 32: 71-74. 4. … National Coordinating Council for Medication Error Reporting and Prevention; 2005 December.

312. Content-Specific Versus Process-Focused Checklists | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxchecklists-3.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Content-Specific Versus … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Sibbald and colleagues found in several studies that the use of this checklist reduced diagnostic error

313. Content-Specific Versus Process-Focused Checklists | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-3.html
     September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Content-Specific Versus … Next Page Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Sibbald and colleagues found in several studies that the use of this checklist reduced diagnostic error

314. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 1: Why Patient Narratives Matter (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol1.pdf
     July 01, 2023 - Hopkins University Christina Yuan Johns Hopkins University Helen Haskell Mothers Against Medical Error … 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.

315. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/tools/index.html
     August 01, 2024 - primary care offices consistently show that the process for managing tests is a significant source of error … a checklist and other resources to help patients understand what they can to do prevent diagnostic error … Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error

316. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html
     June 01, 2023 - Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute … Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. … Families as partners in hospital error and adverse event surveillance. … The Public’s Views on Medical Error in Massachusetts. … Patients’ perspectives of diagnostic error: a qualitative study.

317. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.html
     June 01, 2023 - Measurement is essential for improving diagnosis and reducing diagnostic error: a report from the Institute … Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. … Families as partners in hospital error and adverse event surveillance. … The Public’s Views on Medical Error in Massachusetts. … Patients’ perspectives of diagnostic error: a qualitative study.

318. Clarification in Using Different Paradigms and Terms for Improvement Efforts | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology6.html
     April 01, 2025 - standards used to assess care established a priori, before an event, or was something declared to be “an error … How were judgments of “error” and preventability determined?

319. Issue Brief Describes Strategies for Improving Clinician Psychological Safety in Reporting Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/issue-brief-diagnostic-error.html
     September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error

320. A Strategic Approach for Funding Research: The Agency for Healthcare Research and Quality’s Patient Safety Initiative 2000–2004 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keyes.pdf
     January 01, 2004 - Woolf, Characterizing Medical Error: A Primary Care Study). 2. … Thomas, Teamwork and Error in Neonatal Intensive Care). … Federal Government had ever made to combat medical error. … For example, five grants address the epidemiology of error as a principal goal. … Error, stress, and teamwork in medicine and aviation: cross sectional surveys.