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361. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-5.html
     June 01, 2020 - Reducing Diagnostic Error: Measurement Considerations. October 2019. … Diagnostic Error Change Package. … The next organizational challenge: finding and addressing diagnostic error. … Minimizing diagnostic error: the importance of follow-up and feedback. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

362. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-5.html
     June 01, 2020 - Reducing Diagnostic Error: Measurement Considerations. October 2019. … Diagnostic Error Change Package. … The next organizational challenge: finding and addressing diagnostic error. … Minimizing diagnostic error: the importance of follow-up and feedback. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

363. Tool 3J: Delirium Evaluation Bundle | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/delirium-evaluation.html
     January 01, 2013 - Short Portable Mental Status Questionnaire Question Response Error? … * A mistake on ANY part of this question should be scored as an error. … 7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment * One more error … One less error is allowed if the patient has had education beyond the high school level.

364. Final Progress Report: Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS) (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
     January 01, 2025 - Human error. New York, NY: Cambridge University Press; 1990. 14. … Human error: models and management. BMJ. 2000;320(7237):768-70. 19. Stewart-Amidei C. … Error; 2009. https://psnet.ahrq.gov/glossary/error. Accessed November 19, 2018. 36. … Epidemiology of medical error. BMJ. 2000;320(7237):774. doi: 10.1016/s0041-3879(56)80044-5 37. … https://psnet.ahrq.gov/glossary/error 42.

365. FileNewTemplate
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module5.pptx
     January 01, 1995 - Cross-Monitoring is… A process of ongoing monitoring to recognize risk or unfolding error An opportunity … prevention and/or error interruption mechanism for the team, ensuring that mistakes or oversights are … The insurer realized their error and covered the mammogram. … The insurer realized their error and covered the mammogram. … A shared mental model serves as an error reduction strategy, and caregivers who understand the plan monitor

366. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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 Frequency … 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. … unreported because they do not accord with clinician-derived notions of what constitutes a medical error

367. 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.

368. 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

369. 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.

370. Final Progress Report: Using Barcode Technology to Improve Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gandhi-report.pdf
     January 01, 2024 - Initial work focused on determining the baseline dispensing error rate, type, and severity before implementation … The physicians assessed the level of harm that could have been caused by each error, had it not been … To this regard, we developed a medication administration error observation instrument. … assessors to the purpose of study; and excluded the controlled substance fill process (a process with low error … rates at baseline) from the study, which may bias the combined decrease in error rates toward a larger

371. Diagnostic Safety Issue Brief 21 Diagnostic Stewardship as a Model To Improve the Quality and Safety of Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/dx-safety-21-diagnostic-stewardship.pdf
     August 01, 2024 - improve diagnostic testing should target breakdowns in the testing process that lead to diagnostic error … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Analysis of diagnostic error cases among Japanese residents using diagnosis error evaluation and research … Diagnostic stewardship to prevent diagnostic error. … Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine;

372. 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.

373. 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.

374. 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.

375. Veinte consejos para ayudar a evitar errores medicos (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/20tipssp.pdf
     November 01, 2011 - errores médicos Uno de cada siete pacientes de Medicare que se atienden en hospitales experimenta un error

376. 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

377. 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.

378. 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

379. Diagnostic Safety Issue Briefs | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs.html
     April 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

380. TeamSTEPPS for Office-Based Care: Situation Monitoring | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/officebasedcare/module5/office_sitmon-ig.html
     September 01, 2015 - Cross-monitoring is a process of ongoing monitoring of the environment of care to recognize risk or unfolding error … Cross-monitoring is not a way to "spy" on other team members, but a way to provide a safety net or error … prevention/error interruption mechanism for the team, ensuring that mistakes or oversights are caught … The insurer realized their error and covered the mammogram.  … A shared mental model serves as an error reduction strategy, and caregivers who understand the plan monitor