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41. Final Progress Report: Validation of an Innovative Approach to Error Reduction (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/blumenthal-report.pdf
    January 01, 2024 - Final Progress Report: Validation of an Innovative Approach to Error Reduction Final Progress Report … Validation of an Innovative Approach To Error Reduction Principal Investigator: David Blumenthal, … SCOPE The significance of the medical error problem is now well known. … The definition of a medical error was a critical issue for this investigation. … We defined a preventable adverse event as an adverse event associated with an error.

42. Final Progress Report: Quality Care and Error Reduction in Rural Hospitals (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
    January 01, 2024 - Final Progress Report: Quality Care and Error Reduction in Rural Hospitals Principal Investigator: … , and identify the best practices for error reduction in rural healthcare settings. … Results: Profound professional differences in definitions of error, limited recognition of error, and … as an error in each setting and what was reported. … When the nurse gives the wrong dose, it is recognized as an error.

43. Final Progress Report: Problem Density, Workload, and Medical Error in Primary Care Practice: a WREN Study (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/temte-report.pdf
    January 01, 2024 - This in turn may affect the likelihood of medical error. … Perceived Medical Error. … error involve the primary care setting. … Workload may contribute to error. … Error in medicine: adverse events in intensive care.

44. 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

45. 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
    June 02, 2025 - 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!

46. The Impact of a Patient Safety Program on Medical Error Reporting (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Woolever.pdf
    January 01, 2001 - The Impact of a Patient Safety Program on Medical Error Reporting 307 The Impact of a Patient Safety … Program on Medical Error Reporting Donald R. … Error reduction as a system problem. In: Bogner MS, editor. Human error in medicine. … Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994. 13. … Epidemiology of medical error. BMJ 2000;320:774– 85.

47. Hand Hygiene Observational Audit Tracking Tool (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
    December 01, 2021 - :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR

48. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/educational-bundles/indwelling-urinary-catheteruse/catheter-insertion/unlicensed-staff/scenario-instr.docx
    March 01, 2017 - · Some scenarios may have only one error while others will have more. · Consider using TeamSTEPPS for … Error/Corrective Action: Hand hygiene was not performed upon entering or leaving the room. … Error/Corrective Action: Gloves should be worn when handling a resident’s catheter, the catheter tubing … Error/Corrective Action: Both staff members should be wearing gloves since both are handling either the … Error/Corrective Action: Hand hygiene should always be performed when exiting a resident’s room.

49. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
    January 01, 2002 - Organizational Climate, Stress, and Error in Primary Care: The MEMO Study 65 Organizational Climate … , Stress, and Error in Primary Care: The MEMO Study* Mark Linzer, Linda Baier Manwell, Marlon Mundt … * Occupational Stress and PReventable Error measure. … Climate, Stress, and Error in Primary Care 77 References 1. Firth-Cozens J. … Organizational culture and medication error reporting.

50. Silence A Commentary | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/silence.html
    August 01, 2017 - and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Error … This is what it feels like when you lose a loved one to a medical error. … , a systems error, or both. … In the past, patients experienced only silence and abandonment after a medical error. … The many faces of error disclosure: A common set of elements and a definition .

51. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions1.html
    June 01, 2023 - Inpatient-to-Outpatient Transitions Next Steps and a Call to Action References Diagnostic error … Transitions of care with potential for diagnostic error In healthcare and other industries, transitions … commission, communication errors may follow similar patterns and are particularly relevant to diagnostic error … Transfer of information. 5 However, few strategies focus specifically on reducing diagnostic error

52. 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.

53. 45-Iscr-Pathway-Audit-Tool (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/45-iscr-pathway-audit-tool.xlsx
    June 01, 2023 - Advance care planning completed 0 0 ERROR:#DIV/0! … Carbohydrate drink consumed 0 0 ERROR:#DIV/0! … Wound protector used 0 0 ERROR:#DIV/0! Tranexamic acid administered 0 0 ERROR:#DIV/0! … Patient up in the chair 0 0 ERROR:#DIV/0! … Regular diet POD 0 or POD 1 0 0 ERROR:#DIV/0! Early mobilization 0 0 ERROR:#DIV/0!

54. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses1.html
    August 01, 2022 - high-risk environment where physicians and nurses are particularly susceptible to making a diagnostic error … errors. 4 The National Academies of Sciences, Engineering, and Medicine (NASEM) defines diagnostic error … or (b) communicate that explanation to the patient.” 5 Even a conservative estimate of diagnostic error … occurring in 5 percent of ED visits translates to about 7 million cases of ED-based diagnostic error

55. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
    July 17, 2008 - The purpose of voluntary medication error reporting is to identify these sources of error. … Medication Error Report Data The MEDMARX program assigns a unique record number to each error report … 28.4 22.6 6.0 B Error occurred but it did not reach the patient 14.9 23.9 40.9 C Error occurred … a The number of error types exceeds the number of reports for severity Categories B – I because error … Type of Error Omission and improper dose/quantity were the two most frequently reported error types,

56. 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.

57. Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
    March 21, 2008 - or no error, and categorized the error according to the International Taxonomy of Errors in Primary … ” and “error.” … error occurred. … Frequency of error by type of medication management and type of error Type of medication management … If detected, an error might require additional effort (mitigation transactions) to resolve the error

58. Final Progress Report: Minimizing Error, Maximizing Outcome (MEMO): The Physician Worklife Study II (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/linzer-schwartz-report.pdf
    January 01, 2024 - Low information emphasis predicts likelihood of future error. … Stress and Preventable Error measure, or OSPRE). 3. … Organizational climate, stress, and error in primary care: the MEMO Study. … MEMO: Minimizing Error, Maximizing Outcome. … Error in medicine. JAMA, 1994: 272:1851-7.

59. Appendix A. Database Search Strategy | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-test-result-communication-apa.html
    July 01, 2024 - Reactions” or “Incidental Findings” diagnos* adj2 (test* or procedur* or imag* or lab* or delay* or error … procedur* or diagnos* NEAR/2 imag* OR diagnos* NEAR/2 lab* OR diagnos* NEAR/2 delay* OR diagnos* NEAR/2 error … /exp OR ‘incidental findings’ OR (diagnos* NEXT/2 (test* OR procedur* OR imag* OR lab* OR delay* OR error … diagnos* N2 procedur* OR diagnos* N2 imag* OR diagnos* N2 lab* OR diagnos* N2 delay* OR diagnos* N2 error

60. 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