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441. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Intr…

442. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Intr…

443. Conclusions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-5.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Conclusions Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introducti…

444. Conclusions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-5.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Conclusions Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introducti…

445. Improving the Safety and Quality of Medications and Diagnosis | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-schiff.html
     July 01, 2017 - Schiff and colleagues developed an error classification system that defined and grouped cases by diagnosis … and error type.

446. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/instructor/scenarios/dental.html
     March 01, 2014 - brings to light the fact that this drug is an incorrect choice for a pregnant woman, the unfolding error … If the clinician had not recognized the error, the pharmacist would elevate the challenge to the second … resource management is to prevent work overload or situations that compromise patient care and/or lead to error … If even one team member used the appropriate skills, the problem would have been recognized and an error

447. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - the ICU to the general ward face numerous obstacles, placing them at significant risk for diagnostic error … focus on clinical criteria such as ICU readmissions, few focus explicitly on preventing diagnostic error … embedding diagnostic pauses, and measuring post discharge diagnostic outcomes can mitigate diagnostic error

448. What Exactly Is Patient Safety? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
     July 02, 2008 - Error traps (i.e., unpredictable situations in which error is highly likely) are another vivid concept … Some, such as understanding human error, come from human physiology and psychology. … Human error. Boston: Cambridge University Press; 1990. 12. Leape LL. Error in medicine. … Error, stress, and teamwork in medicine and aviation: Cross- sectional surveys. … Evaluation of error in medicine: Application of a public health model.

449. Cognitive Load Theory and Its Impact on Diagnostic Accuracy - Issue Brief 17 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load.pdf
     May 01, 2024 - the Institute of Medicine in 1999, was one of the first publications to bring the issue of medical error … In addition, diagnostic error may result in serious harm to more than 500,000 Americans each year across … often takes place after the error has occurred. … Burden of serious harms from diagnostic error in the USA. … Diagnostic error in internal medicine.

450. TeamSTEPPS Specialty Scenarios: Dental (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/dental.pdf
     March 19, 2014 - brings to light the fact that this drug is an incorrect choice for a pregnant woman, the unfolding error … If the clinician had not recognized the error, the pharmacist would elevate the challenge to the second … resource management is to prevent work overload or situations that compromise patient care and/or lead to error … If even one team member used the appropriate skills, the problem would have been recognized and an error

451. Directions for Future Research | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-4.html
     June 01, 2023 - move away from previous practices of asking respondents if they experienced medical or diagnostic “error

452. Directions for Future Research | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-4.html
     June 01, 2023 - move away from previous practices of asking respondents if they experienced medical or diagnostic “error

453. | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/publications/search.html?page=3
     August 01, 2022 - Safety Issue Brief #6: This issue brief discusses what is known about the contribution of diagnostic error … Safety Issue Brief #5: Despite the enormous financial cost and patient harm resulting from diagnostic error … Number: 21-0003 Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error

454. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lipsitz-report.pdf
     January 01, 2024 - Two physicians independently reviewed each TCE to determine if a medical error had occurred. … combined in a third model to identify factors that conferred a higher risk for experiencing a medical error … geriatrician and hospitalist who reached consensus about whether a particular event was a medical error … In 14.7% of all discussions, a medical error was identified. … Furthermore, it suggests that the discharging service and time of day may be associated with risk of error

455. Final Progress Report: Shared Decision Making in Surgery To Improve Patient Safety and Reduce Liability (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
     January 01, 2024 - Resource consumption for patient complaints was similar to medical error resolution. … the following data were abstracted: medical service and procedure associated with the complaint or error … Mean staff time per complaint file (10.7 hours) was double that for error files (5.8 hours, p<0.01). … In contrast, most error files (62%) involved some compensation for treatment compared to the minority … The size of compensation was higher in error files (mean $4,302) compared to complaints (mean $702,

456. Sustainability: Learning From Defects: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
     December 01, 2017 - ” — James Reason, Human Error, 1990 1 Slide 8: AHRQ Safety Program for Surgery—Sustainability … Slide 18: Rank Order of Error Reduction Strategies 5 Image: Chart captioned "Strength of Interventions … Human Error: models and management. BMJ 2000;320:768-70. PMID: 10720363. … Selecting the best error-prevention "tools" for the job. 2006. 

457. Module 7: Putting It All Together
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/diagnosis-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.

458. 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.

459. Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician’s Office (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Galt.pdf
     April 23, 2004 - Error management Most offices had a formal system in place for reporting an actual error in the employment … site, and indicated they report hazardous situations that could lead to an error. … Error disclosure to patients was the general practice reported by these offices. … exchange of information that could contribute to future error prevention. … must be changed to improve office error-reduction practices.

460. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-2.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Introduction Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introduct…