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361. Tool 5 (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/postdischarge-doc.html
     March 01, 2025 - _____________________ ___ Intentional nonadherence ___ Inadvertent nonadherence ___ System/provider error … _____________________ ___ Intentional nonadherence ___ Inadvertent nonadherence ___ System/provider error … _____________________ ___ Intentional nonadherence ___ Inadvertent nonadherence ___ System/provider error

362. Organizations and Diagnostic Performance: How to End Up with ‘Fewer Misses & More Hits’ that Mean Something to Patients and Their Families (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/mcdonald-summit2016-breakout.pdf
     June 02, 2025 - reporting (ERR) of images and lab results and for EHRs with office problems that could lead to diagnostic error … #2: FOR KNOWLEDGE: Developmental and Evaluative Research within Organizations (H4-6)  Articulate dx error … Model Acrobat Accessibility Report Accessibility Report Filename: AHRQ Dx Error

363. Final Progress Report: NPSF Joint Medical-Legal Conference at SMU (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/nance-report.pdf
     January 01, 2025 - fiduciary responsibility, to be fully, completely, promptly, and honestly informed when a medical error … the act of informing a patient and/or family of the fact of an injury resulting from a mistake or error … Every patient who has been apologized to and fully informed about the details of a medical error that … The CEO of the hospital within 24 hours went to the family, fully disclosed and discussed the error … I listen to the mediator, and every time he says, now this is an egregious error...it’s a big error

364. Chapter 2. Electronic Searchable Catalog | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program2.html
     April 01, 2018 - Clinical area— the medical specialty related to the article, including in which field the case/error … Error types— classification of error(s) in order to identify root cause(s) and offer solution(s). … Data Entry The data entry process was designed to minimize error in abstraction through a series of … To reduce the possibility of error and facilitate use of the query tool, there are only two write-in … , and Root Cause Analysis will also be selected because they are specific examples of Error Analysis.

365. Surveys on Patient Safety Culture (SOPS) Hospital 2.0 Survey: 2024 User Database Report Part II (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/hospital/2024-hospital-database-report-appendix.pdf
     January 01, 2024 - Response to Error 62% 67% 62% 65% 64% 10. … Response to Error 60% 66% 66% 58% 10. … Response to Error 65% 63% 65% 67% 10. … Communication About Error 74% 81% 6. … Response to Error 63% 69% 10.

366. Final Progress Report: Patient Safety and the Primary Care Testing Process (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/elder-report.pdf
     January 01, 2025 - • Secondary analysis of 600 error reports and transcripts from 18 focus groups from the AAFP DCERPS … Human factors classifications of Risk and Error that produce breaks in quality and safety Safe, … Nurses' perceptions of error communication and reporting in the intensive care unit. … What do family physicians consider an error? … Stretching the search for the 'why' of error: The Systems Approach.

367. Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital-version-2-resource-list.pdf
     December 01, 2024 - Response to Error, #2. Composite Measure 3. Teamwork 1. … Communication About Error 1. … Response to Error 1. … Missed nursing care is a subset of the category known as error of omission. … Communication About Error Composite Measure 8. Response to Error Composite Measure 9.

368. Consumer Decision Points: Using Online Reports to Gauge Quality of Physician Performance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20110511/patrick-mccabe.pdf
     June 02, 2025 - . – Significantly bad experiences with physician error in the past. … serious condition – MS, Cancer Big Problem with MD • Misdiagnosis or no diagnosis • Medication error

369. Consumer Decision Points: Using Online Reports to Gauge Quality of Physician Performance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/talkingquality/resources/podcasts_webinars/Patrick_McCabe.pdf
     June 02, 2025 - . – Significantly bad experiences with physician error in the past. … serious condition – MS, Cancer Big Problem with MD • Misdiagnosis or no diagnosis • Medication error

370. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/refs.html
     May 01, 2016 - The Public's Views on Medical Error in Massachusetts, Commissioned by the Betsy Lehman Center for Patient … Safety and Medical Error Reduction. … Predictors of chemotherapy patients' intentions to engage in medical error prevention. … Brief report: Hospitalized patients' attitudes about and participation in error prevention.

371. Advances in Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances/index.html
     July 01, 2022 - Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff Organizational Climate, Stress, and Error … Grems, Elizabeth Sloan The Impact of a Patient Safety Program on Medical Error Reporting (   PDF , … Dittus The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence … Weinger Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? … Hilborne Standardizing Medication Error Event Reporting in the U.S.

372. Environmental Scan of Patient Safety Education and Training Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
     June 01, 2013 -  Error types—classification of error(s) in order to identify root cause(s) and offer solution(s … Data Entry The data entry process was designed to minimize error in abstraction through a series of … To reduce the possibility of error and facilitate use of the query tool, there are only two write-in … , and Root Cause Analysis will also be selected because they are specific examples of Error Analysis … Reducing Medical Error Reducing Patient Injuries Safer Patients Teach Patient Safety Root

373. Module 7: Putting It All Together
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module7-all-together.pptx
     January 01, 2008 - to complete this module: 45 minutes (19 slides) 1 Slide Module 7 Objectives Summarize diagnostic error … After completing this module, participants will be able to: Summarize diagnostic error and its importance … can be realized with the successful use of the TeamSTEPPS tools and strategies. 2 Slide Diagnostic Error … Diagnostic error is a patient safety issue. … Every member of the team can help prevent a diagnostic error.

374. Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast - Bakdash (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-sops-teamstepps-webcast-bakdash.pdf
     January 01, 2022 - and Work Pace (4 items) • Organizational learning – Continuous Improvement (3 items) • Response to Error … • Supervisor, Manager or Clinical Leader Support for Patient Safety (3 items) • Communication About Error

375. Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
     April 01, 2021 - system for hospitalized patients, and Project 2 addressed the common but understudied area of diagnostic error … Bridging the gap between systems-based and cognitive contributions to diagnostic error . … Bridging the gap between systems-based and cognitive contributions to diagnostic error .

376. 2018 Hospital SOPS Database Report Executive Summary Infograpic (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsrptexecsum_0.pdf
     March 01, 2018 - change Areas of potential for improvement for most hospitals 470/o Nonpunitive Response to Error … composites 35% of hospitals Increased by 5 percentage points or more on Non positive Response to Error

377. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - If the focus is on the process and the system factors that facilitated the error, the process can be … adjusted to minimize human error, resulting in fewer opportunities to err again. … (Table 1) Table 1: Behavior Classification Normal Error (Human Error) At-risk Behavior … If a normal error has occurred, the provider undoubtedly feels bad and should be supported. … questions such as "Why was there human error?

378. Understanding SOPS Surveys: A Primer for New users -Gray (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/2-SOPS_101_Webcast_2020-Gray.pdf
     January 01, 2020 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management … • Diagnostic Safety (Medical Office)—Spring 2021 ► Assist in identifying processes and sources of error

379. Table of Contents: Volume 1. Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/TableofContents_Vol1.pdf
     January 01, 2025 - Improving Error Reporting in Ambulatory Pediatrics with a Team Approach Daniel R. … Taxonomies and Measurement Development of a Comprehensive Medical Error Ontology Pallavi Mokkarala … A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care Ranjit Singh … xi Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy … Error Producing Conditions in the Intensive Care Unit Frank A. Drews, Adrian Musters, Matthew H.

380. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence1.html
     April 01, 2025 - Diagnostic error is a major source of preventable harm and increased costs across healthcare settings … If we are to achieve diagnostic excellence and the goal of zero preventable harm from diagnostic error