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61. The Contribution of Diagnostic Error to Maternal Mortality and Severe Maternal Morbidity | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-2.html
    September 01, 2021 - Mortality During and Immediately After Childbirth: State of the Science The Contribution of Diagnostic Error … Immediately After Childbirth: State of the Science Introduction The Contribution of Diagnostic Error … adaptation of the multidisciplinary Safer Dx framework for measuring, monitoring, and improving diagnostic error … Measurement and learning from diagnostic error (and circumstances without diagnostic error) must include … Using the Safer Dx Framework 16 as a Model for Improvement of Diagnostic Error and Contributions to

62. Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy 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-David_13.pdf
    March 19, 2008 - Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process … Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process … reactive error management. … Reducing prescribing error: Competence, control and culture. … Chemotherapy error reduction: A multidisciplinary approach to create templated order sets.

63. 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.

64. Opportunities and Challenges Ahead | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship8.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 … models for populations and settings in which problems with the testing process contribute to diagnostic error … efforts to measure these organization-level outcomes as well as those directly related to diagnostic error

65. 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.

66. Diagnostic Stewardship Interventions To Reduce Diagnostic Error | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship5.html
    August 01, 2024 - Improve the Quality and Safety of Diagnosis Diagnostic Stewardship Interventions To Reduce Diagnostic Error … 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 … with tracking, followup, and interpretation of completed test result reports contribute to diagnostic error

67. Final Progress Report: Improving Patient Safety by Examining Pathology Errors (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/raab-report.pdf
    January 01, 2025 - and diagnostic error. … Error detection measures: Error frequencies, error proportions, and error rates. … Error and error reduction in pathology. Arch Pathol Lab Med 2005;129:1228-1233. … Pathology error taxonomy. … Anatomic pathology error.

68. Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists.html
    September 01, 2020 - Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction Next Page … Table of Contents Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction … Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction.

69. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/brock.html
    August 01, 2017 - and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary Error … Interventions to improve skills around error disclosure constitute a good test of the OCS; successful … Training involved a mix of didactic and error disclosure simulation. … Error disclosure: A new domain for safety culture assessment. … Implementing an error disclosure coaching model: a multicenter case study.

70. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety.html
    September 01, 2023 - Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error.

71. References | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-sustainability-centers-of-excellence-references.html
    April 01, 2025 - Payment innovations to improve diagnostic accuracy and reduce diagnostic error. Health Aff . … Report Highlights Public Health Impact of Serious Harms From Diagnostic Error in U.S. … Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine. … Defining diagnostic error: a scoping review to assess the impact of the National Academies’ report Improving

72. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality.html
    September 01, 2021 - Immediately After Childbirth: State of the Science Introduction The Contribution of Diagnostic Error … References Issue Brief 6 Contents Introduction The Contribution of Diagnostic Error

73. HSOPS | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicomp5a.html
    January 01, 2013 - statistically significant improvement was found in two dimensions: "feedback and communication about error … statistically significant improvement was found for two dimensions: "feedback and communication about error … The number of units classified as "needing improvement" within the "feedback and communication about error … Nonpunitive Response to Errors 60.6% 59.1% 0.015 0.167 0.114 Feedback and Communication About Error

74. A Conceptual Model for Disclosure of Medical Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
    January 01, 2004 - Error factors included level of harm and whether patients and others were aware of the error and the … The level of harm caused by the error and whether patients and others were aware of the error and any … You put yourself in the hands of your professional…” Error factors The outcome of the error—who … Error outcome and patient awareness of the error outweighed any other determinants for disclosure related … to the error itself.

75. Final Progress Report: Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/lamb-report.pdf
    January 01, 2024 - Most if not all knowledge of error rates in radiotherapy is from error reporting. … Error reporting is known to underestimate error prevalence because not all errors are detected, and barriers … Error bars represent one standard error. … The result of our retrospective error search showed that errors were underreported: the actual error … rate was 66% greater than the reported error rate.

76. Using Home Visits to Understand Medication Errors in Children (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Walsh_74.pdf
    May 28, 2008 - the error. … error without injury). 3. … Not a medication error (excluded from the study). 10 A medication error is an error in drug ordering … Was a possible error found? … Was anyone notified of the error?

77. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
    November 29, 2004 - , a lipid-control error, or a pharmacy error. … : (a) glycemic-control error; (b) lipid-control error; or (c) pharmacy error. … N % Error N % Error status unknown N % A1c < 7% At goal 1,371 33.0% A1c 7 – 7.9% … Column C provides the error rate in the subgroup at risk, while column D provides the error rate in … another type of error.

78. Learning from Errors in Ambulatory Pediatrics (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
    February 01, 2004 - Error reports were then read to ensure that each report represented a mutually exclusive error. … Reports that included more than one error were divided into separate error reports. … Examples of error reports Medical domain categories Example error report Preventive Medicine “ … Examples of error reports, cont. … Error discovered.

79. Final Progress Report: Reducing Harm to Patients from Diagnostic Errors (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/berner-report.pdf
    January 01, 2025 - Diagnostic Error in Medicine. Adv Health Sci Educ Theory Pract. 2009 Sep;14 Suppl 1. … Diagnostic error in medicine: introduction. … Educational strategies to reduce diagnostic error: can you teach this stuff? … Diagnostic error in medical education: where wrongs can make rights. … Reducing diagnostic error with computer-based clinical decision support.

80. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
    July 01, 2003 - Data elements and error characteristics Error characteristics—type of error Illegible prescription … No error A Circumstances or events that have the capacity to cause error Error, no harm B … , did constitute an error. … If more than one error was found per prescription, each error was evaluated separately. … , thus qualifying to be an error.