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81. 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.

82. 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.

83. 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?

84. 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.

85. 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.

86. 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.

87. 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.

88. References | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses6.html
    August 01, 2022 - What interventions could reduce diagnostic error in emergency departments? … Understanding the social in diagnosis and error: a family of theories known as situativity to better … inform diagnosis and error. … Interdisciplinary communication: an uncharted source of medical error? … Diagnostic error in medicine: analysis of 583 physician-reported errors.

89. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: 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-2/vol1/Advances-West_102.pdf
    March 31, 2008 - Error Coding and Classification All error reports were reviewed and then coded by teams of at least … attributes could be assigned to the same error. … Multiple roles could be involved in any single error event. … Attributes of errors related to harm (N = 608) Error type Error attributes [N (%)] Future risk … Medical error taxonomies. A research forum; 2003.

90. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
    January 01, 2004 - These included where in the process the error occurred, what disciplines were involved, the error distribution … error occurred that resulted in a patient death. … error code. … Unit-dose dispensing of the drug involved in the error will prevent an error with that drug, but not … Human error. Cambridge, UK: Cambridge University Press; 1990. 8.

91. Diy-Run-Chart-Tool (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/diy-run-chart-tool.xlsx
    June 02, 2025 - :#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

92. Introduction to Diagnostic Errors | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.html
    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 … a patient. 1 , 7 Unfortunately, identification of inaccurate diagnostic reasoning and diagnostic error … often takes place after the error has occurred. … Retrospective investigation into the contributing factors that led to the diagnostic error are subsequently

93. Final Progress Report: Prescribing Errors in Ambulatory Pediatric Care (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/basco-report.pdf
    January 01, 2024 - Key Words: medication error, children B. … Dosing Error Results: We are still conducting these analyses. … Factors associated with receipt of error, answering Aim 3. … In the LASA error study, no patient characteristic was predictive of receipt of an error. … The LASA error frequencies suggested by these data are undoubtedly underestimates of the true LASA error

94. A System to Describe and Reduce Medical Errors in Primary Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kaprielian_9.pdf
    January 01, 2007 - there was concern about a possible error. … Figure 2 shows the distribution of error types in 2005 and 2006. … Distribution of error types over 2 years (all CFM clinics). … “ No error 1. adverse outcome, no error 2. unhappy patient, no adverse outcome, no … error 3. no error, patient choice Please fold this form in half and staple it, or place in

95. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
    January 01, 2024 - to detect and correct the error before it reaches patients. … This represents a prescribing error capture rate of 74%. … Medication error reporting systems. In Medication Errors. 2nd ed. … The probability and management of human error. … Technique for human error rate prediction (THERP).

96. Special Considerations for Measurement of Diagnostic Safety | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-2.html
    June 01, 2020 - The recent NASEM report defines diagnostic error as the “failure to establish an accurate and timely … longitudinal continuum of patient care, as well as pragmatic tools to help measure and address diagnostic error … evaluated in research settings, few HCOs take a systematic approach to measure or monitor diagnostic error … Use of a single method to identify diagnostic error, such as manual chart reviews or voluntary reporting … Table 1 describes various data sources and strategies that could enable measurement of diagnostic error

97. Final Progress Report: Utility of Predictive Systems in Diagnostic Errors (UPSIDE) (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/auerbach-report.pdf
    January 01, 2025 - Results: Overall, 550 patients (23.0%, 95% CI 20.9-25.3%) experienced a diagnostic error. … Key Words: Diagnostic error, Patient safety, diagnosis, quality, health services research 3. … We also created models to understand the factors that make a diagnostic error more or less likely. … rates deviated significantly from the group mean error rate. … underwent review, 550 (23.0%, 95% CI 20.9-25.3%) experienced a diagnostic error

98. Risk-Based Patient Safety Metrics (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
    March 25, 2008 - Error measurement has many limitations, including the issues of error identification, hindsight bias … If an error rate is: Identified errors Potential opportunities for that error to occur then, the … Error is attributed correctly. … .19 Similar to error identification through chart review, correct determination of a numerator of error … Therefore, calling something “human error” or “error” might not be factually meaningful.

99. Final Progress Report: Implementing a Program of Patient Safety in Small, Rural Hospitals (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/jones-report.pdf
    January 01, 2024 - ; 50%, by cause of error; and 20%, by therapeutic class of the drugs involved in an error. … We never went past the type of error. … (n = 30) Severity of error 13 Type of error 22 Phase (node) of medication use process in which error … originated 11 Cause of the error 14 Drugs involved in the error 22 Actions taken in response to … an error report to prevent error from recurring 12 Source: Outcomes survey 17 Table 3.

100. OR-to-ICU Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions4.html
     June 01, 2023 - This transition is prone to technical and diagnostic error due to not only the high patient acuity and … The study did not explicitly look at medical error. … It is challenging to explicitly evaluate diagnostic error as an outcome in the postoperative period: … Although medical error and information omission are common outcomes in many studies, none isolate the … effect of handoff standardization on diagnostic error in the postoperative period.