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321. 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.

322. 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.

323. Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship.html
     August 01, 2024 - as a Model To Improve the Quality and Safety of Diagnosis Introduction Background Diagnostic Error … in the Testing Process Diagnostic Stewardship Interventions To Reduce Diagnostic Error Diagnostic

324. 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.

325. 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

326. 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

327. 2024 SOPS Hospital Database Report Executive Summary Overview Infographic (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/hospital/2024-hospital-database-report-summary.pdf
     January 01, 2024 - Lowest Scoring Composite Measures Response to Error 64% of respondents reported that staff are treated … Database Results from 2021 to 2024 Communication About Error had t he largest average percent positive

328. 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

329. 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.

330. 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.

331. 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.

332. 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

333. 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.

334. 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

335. Standardizing Ambulatory Care Procedures in a Public Hospital System to Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kleinpeter.pdf
     January 01, 2004 - This error-reduction strategy will also improve communication between the patient and their physicians … Most studies that report on medical error are primarily focused on hospitalized patients. … In many individual hospital data systems, data may be extracted regarding medical error by examining … We used the characteristics of an error focus strategy as outlined by Layde et al.,6 to implement the … Error in medicine. JAMA 1994;272:1851– 7. Advances in Patient Safety: Vol. 4 162 6.

336. Chapter 6. Assessment and Process Evaluation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/chapter-6.html
     July 01, 2022 - Special Considerations: The National Coordinating Council for Medication Error Reporting and Prevention … This index considers factors such as whether the error reached the patient and, if the patient was harmed … Table 6 explains the different categories of medication error classification. … Different categories of medication error classification were adapted into the table below.

337. Chapter 6. Assessment and Process Evaluation | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/chapter-6.html
     July 01, 2022 - Special Considerations: The National Coordinating Council for Medication Error Reporting and Prevention … This index considers factors such as whether the error reached the patient and, if the patient was harmed … Table 6 explains the different categories of medication error classification. … Different categories of medication error classification were adapted into the table below.

338. TeamSTEPPS® Diagnosis Improvement: Module 7: Putting It All Together (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module7-presenters-notes.pdf
     January 01, 2008 -                                                                             • Summarize diagnostic error … Slide 3 Diagnostic Error Is a Patient Safety Issue Getting  the  right  diagnosis  in  a  timely … Diagnostic error is a patient safety issue. … Every member of the team can help prevent a diagnostic error. … It is an effective antidote to many of the problems that lead to diagnostic error: overconfidence,

339. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
     August 01, 2023 - Diagnostic Error in Pediatrics: A Narrative Review. Pediatrics . … Diagnostic error in children presenting with acute medical illness to a community hospital. … Committee on Diagnostic Error in Health Care. Improving diagnosis in health care. … Primary care pediatricians' interest in diagnostic error reduction. Diagnosis (Berl) . … Factors Associated With Diagnostic Error on Admission to a PICU: A Pilot Study.

340. Final Progress Report: Automated Medical Interviewing for Diagnostic Decision Support in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/newman-toker2-report.pdf
     January 01, 2025 - Usability (Ease of Use, Error, Efficiency) Ease of use, error rate, and efficiency analyses are summarized … Time per click was not associated with error based on age entry misclick rates. … Second, certain usability design features had more influence on the error rate than others. … Those with access demonstrated greater ease of use, lower error rates, and improved efficiency. … Implications for decision support and error reduction. JGenInternMed. 2005;20(4):334-9. 17.