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481. | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/publications/search.html?page=3
     September 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

482. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
     August 01, 2022 - Addressing the problem of diagnostic error by understanding and optimizing the diagnostic process in

483. Action-Alliance-Agenda-040323 Locked (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-agenda-040323_LOCKED.pdf
     April 25, 2023 - President, Consumers Advancing Patient Safety Founder and President Mothers Against Medical Error

484. Diagnostic Safety Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
     May 01, 2023 - is to create a well-organized office system that fosters sound medical decision making, minimizes error … www.improvediagnosis.org/practice-improvement-tools/open-notes/ Open Notes addresses multiple aspects of diagnostic error … AudioandVideo/WIHIImprovingDiagnosisErrors.aspx In this podcast from IHI, four speakers discussed diagnostic error … kp_shortcut_referrer=kp.org/scal/dex The videos in this series are short and cover a wide range of diagnostic error … and educators on clinical reasoning, critical thinking, and system factors that underlie diagnostic error

485. Medical Injury Identification Using Hospital Discharge Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
     January 01, 2003 - While the IOM report primarily emphasized error reporting systems, focusing on the injuries or adverse … Most current patient safety reporting systems focus on incidence of medical error or negligence. … Perceived blame and punishment for error, however, may be an incentive for concealment and denial. … those resulting from malpractice damages.2 In addition, the determination of negligence or medical error … believe this injury prevention approach is a useful complement to other approaches that focus on error

486. Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Dickerman_84.pdf
     June 04, 2008 - cold” by the Institute of Medicine’s (IOM) 1999 report, To Err Is Human.2 1 The Nature of Error … established the theoretical basis for this understanding through their work in the study of human error … The unit cost per life saved is enormous. 2 How the Environment Contributes to Error What … Error in medicine. JAMA 1994; 272: 1851- 1857. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. … Human error. Cambridge, UK: Cambridge University Press; 1990. 4. Perrow C.

487. Shadowing Another Professional Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/shadowing.html
     December 01, 2012 - Did you observe any error in transcription of orders by the provider you shadowed?       … Did you observe any error in the interpretation or delivery of an order?       5.

488. Chapter 1. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2014/mosurv14chap1.html
     June 01, 2014 - research pertaining to safety, patient safety, health care quality, ambulatory medicine, medical errors, error … It was designed to assess medical office staff opinions about patient safety issues, medical error, and

489. Continuous Respiratory Monitoring and a “Smart” Infusion System Improve Safety of Patient-Controlled Analgesia in the Postoperative Period (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_111.pdf
     June 18, 2008 - patients receiving PCA therapy and implementation of “smart” (computerized) PCA pumps containing dose-error … Our multidisciplinary Medication Error Team includes pharmacists, respiratory therapists, risk managers … team determined that implementation of a modular, computerized IV infusion safety system with dose error … PCA Practice and Patient Monitoring Recognizing opioids’ potential for harm, the Medication Error Team … Conclusion Data indicate that the use of “smart” PCA infusion devices with dose error-reduction systems

490. Use of Data and Measurement in Improving Diagnostic Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/newman-toker-summit2016.pdf
     September 28, 2016 - clinical data warehouses (+/- supported by NLP) HELP MEASURE & TRACK PROBLEMS BIG DATA FOR DX ERROR … NUMERATOR-ONLY Methods NUMERATOR-DENOMINATOR Methods NUMERATOR-DENOMINATOR Methods Big data for Dx Error

491. 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…

492. 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…

493. St. Jude Relies on AHRQ's Hospital Survey on Patient Safety Culture | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips1402.html
     January 01, 2014 - "It's not about blaming them that an error occurred." … These dimensions include nonpunitive response to error, communication openness, hospital management support

494. Spanish Translation of AHRQ's Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospital_survey_composites-spanish.pdf
     October 01, 2009 - Cuando se comete un error, pero es descubierto y corregido antes de afectar al paciente, ¿qué tan a menudo … Cuando se comete un error, pero no tiene el potencial de dañar al paciente, ¿qué tan frecuentemente es … Cuando se comete un error que pudiese dañar al paciente, pero no lo hace, ¿qué tan a menudo es reportado

495. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/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…

496. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module6/module6-care-for-caregiver.pptx
     May 01, 2011 - Wu discusses this concept in his article “Medical Error: The Second-Victim” and the associated “expectation … the second-victim phenomenon even in cases where no adverse event occurred, but they feared that an error … stage. 9 Stage 1: Chaos and Accident Response Stage characterized by the second-victim: Realizing error … During this stage, the second-victim might tell someone about the error/event as their way of asking … Medical error: the second victim. The doctor who makes the mistake needs help too.

497. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-5.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Conclusion Previous Page Next Page Table of Contents Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors Executive Summary Introductio…

498. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
     May 20, 2016 - with drug reaction ∗ Death associated with adverse drug reaction ∗ Death associated with medication error … Procedures  Prophylaxis  Resuscitation  Supervision/management  Triage/transitions  Human error … usual procedures performed in accordance with standards of care) and nosocomial infections  Human error … Multi-professional mortality review: supporting a culture of teamwork in the absence of error finding

499. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.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…

500. 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