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41. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
    January 01, 2003 - First, by definition, recognition that an error has occurred means that the error happened some time … Because of this, recognition that an error has occurred is very difficult.20 Second, even if an error … again, rather than focusing on the underlying cause of the error.40 Nurses do not see error reporting … • Nurses do not recognize an error occurred. • Medication error is not clearly defined. … Medication Administration Error Reporting Survey 489 46.

42. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
    March 05, 2008 - Improving Error Reporting in Ambulatory Pediatrics with a Team Approach Improving Error Reporting in … Medical error reports, 2005 and 2006. … Some examples of error reports in each of these categories are listed in Table 1. … Examples of error reports in pediatric ambulatory practice Communications Error: Child with varicella … Medications Error: Wrong vaccine administered (several similar reports).

43. Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/16658-Gallagher-report.pdf
    January 01, 2009 - occurred, whether and how the error should be disclosed, who should disclose the error, and how the … NAMED Words such as error or mistake used to describe event Was this an error? … and details of how error occurred Discussion to disclose error but only partially disclose details … ,” “near miss,” “minor error,” or “serious error.” … NAMED--MD ERROR NAMED- -MD 46 3 72 3 26 2** 27 4 112 3 124 4 236 4 ERROR NAMED--RN ERROR NAMED-

44. Conclusions and Next Steps | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/maternal-mortality-5.html
    September 01, 2021 - Immediately After Childbirth: State of the Science Introduction The Contribution of Diagnostic Error … Although, many factors that contribute to diagnostic error in maternal health are unknown, there are … feasible solutions, including simulation to both determine the causes of and reduce diagnostic error … More research is needed to identify related factors that contribute to diagnostic error and to determine

45. Final Progress Report: Enhancing the Disclosure Of Medical Errors to Patients (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/gallagher4-report.pdf
    January 01, 2024 - , but 42 percent would explicitly state that an error occurred. … mentioned the error compared with 32 percent who received the less-apparent error. … In addition to his empiric work in error disclosure, Dr. … Physicians’ and Nurses’ Perspectives on Error Reporting in Hospitals. … Content of medical error disclosures. Virtual Mentor. March 2004.

46. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
    June 30, 2004 - Diagnostic testing error reports had more event activity codes than other types of error reports (mean … reports and other error reports. … through a combination of subordinate communication error codes. … Analysis of Medical Error Event Reports 145 8. … Data elements in ASIPS error reports Table 2.

47. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
    January 01, 2004 - The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data 195 … The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data … Abstract This paper examines the impact of an Internet-based method on the collection of medication error … Finally, the missing or unspecified data from the cause-of-error variable decreased from 18.6 percent … Several studies suggest that medical error is the third-leading cause of death in the United States,

48. Next Steps and a Call to Action | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions6.html
    June 01, 2023 - of care represent a vulnerable moment for patients and families with high potential for diagnostic error … Each unique context carries its own risks for diagnostic error. … Table 1 highlights and summarizes specific strategies that can help mitigate diagnostic error at each … Care transitions, sources of error, and potential mitigating strategies Care Transition Latent … to scale up and nationally implement effective tools to mitigate diagnostic error.

49. Tool 1: Readmission Data Analysis and Interpretation (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
    September 20, 2016 - ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0!

50. Final Progress Report: Diagnostic Error in Medicine Conference 2020-2022 (pdf file)
    www.ahrq.gov/sites/default/files/2025-04/castro-report.pdf
    January 01, 2025 - Final Progress Report: Diagnostic Error in Medicine Conference 2020-2022 Title Page – Final Progress … Report Title: Diagnostic Error in Medicine Conference 2020-2022 Principal Investigator: … Increase the visibility and public awareness of diagnostic error; 2. … Diagnostic error in internal medicine. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

51. Final Progress Report: Putting a Face on Hospital Medical Errors: Communication (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/stewart-report.pdf
    January 01, 2024 - Keywords: medical error disclosure, doctor-patient communication, patient safety, quality. … Once a medical error case was selected, we designed a letter simulating disclosing of the error to the … In these four instances, there was no disclosure about the error. … Significance All medical error disclosures are not the same. … and by identifying impact of the error from the PATIENT perspective.

52. Inpatient-to-Outpatient Transitions | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions5.html
    June 01, 2023 - patients transition from the inpatient to outpatient setting, is perhaps the setting where diagnostic error … In one study, 49 percent of patients experienced at least one medical error after discharge, related … review and adjudication process to categorize diagnostic error. … A systematic review of cognitive interventions to reduce diagnostic error across healthcare settings … However, most interventions were not tested directly for error reduction in clinical practice.

53. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
    January 01, 2004 - to the overall error rate found in the prescription error studies. … error-reduction practices might affect error rate. … be an inefficient way to reduce error when the error rate already is quite low. … Several error-reduction practices had surprisingly low error-reduction scores. … Error reporting also receives a low score when it is treated as an error reduction practice.

54. Evaluation of Diagnostic Stewardship Implementation | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship7.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 … stewardship activities are leading to improved diagnosis, improved safety, or reduction of diagnostic error … diagnosis after review/intervention by a diagnostic stewardship team, which could imply a diagnostic error … safety outcomes include diagnostic errors in which testing-related factors are found to contribute to error

55. Diy-Run-Chart-Tool (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/diy-run-chart-tool.xlsx
    June 21, 2021 - :#N/A 25% Dec'12 ERROR:#N/A 25% Jan'13 ERROR:#N/A 25% Feb'13 ERROR:#N/A 25% Mar'13 ERROR: … #N/A 25% Apr'13 ERROR:#N/A 25% May'13 ERROR:#N/A 25% Jun'13 ERROR:#N/A 25% Safety Net Medical … :#N/A 0% Aug'12 ERROR:#N/A 0% Sep'12 ERROR:#N/A 0% Oct'12 ERROR:#N/A 0% Nov'12 ERROR:#N/A … 0% Dec'12 ERROR:#N/A 0% Jan'13 ERROR:#N/A 0% Feb'13 ERROR:#N/A 0% Mar'13 ERROR:#N/A 0% … Apr'13 ERROR:#N/A 0% May'13 ERROR:#N/A 0% Jun'13 ERROR:#N/A 0% Safety Net Medical Home Initiative

56. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-1.html
    March 01, 2022 - Conclusion References The burden of suffering, cost, and waste related to diagnostic error … problem, 3 , 4 an increasingly robust understanding has developed of the factors that lead to diagnostic error … While individual, professional, contextual, patient, and health system factors make diagnostic error

57. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
    January 01, 2016 - Diagnostic Error Measures: For Quality Improvement & Patient Safety Research Diagnostic Error Measures … Diagnostic Error Measures Types of Patient Safety & Quality Measures xxVoluntary Reporting Chart … trigger report • PPV > 70% • Requires programming • Fully automated IOM Definition: Diagnostic Error … JAMA. 2001;285:2114-2120 Wrong-Patient Error Measures Retract-and-Reorder Tool Applied to Complete … Diagnostic Error Measures:�For Quality Improvement & �Patient Safety Research Slide Number 2 Slide

58. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
    March 11, 2005 - AHRQ WebM&M—Online Medical Error Reporting and Analysis 211 AHRQ WebM&M—Online Medical Error Reporting … Online Error Reporting and Analysis 215 Cases.” … Online Error Reporting and Analysis 217 Table 2. … Online Error Reporting and Analysis 221 6. Orlander JD, Fincke BG. … Adverse event/error types among published cases* Figure 1.

59. Grants to Enable Diagnostic Excellence | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
    January 01, 2021 - machine learning models that can be used to retrospectively identify patients in whom a diagnostic error

60. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
    January 01, 2003 - Nursing personnel directly involved in a medical error were interviewed within 2 weeks of the error. … and at times when no error occurred. … and on the error shift differed from times when no error occurred, suggesting that transient working … error was made. … minutes prior to the error.