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81. 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.

82. 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.

83. 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

84. 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.

85. 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

86. 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

87. 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

88. 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).

89. 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

90. 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

91. 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.

92. 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.

93. 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.

94. Developing a Taxonomy for Coding Ambulatory Medical Errors: 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/vol2/Pace.pdf
    January 01, 2004 - We then applied 337 of 421 available taxonomy codes to 608 error reports. … (AAFP)-Linnaeus Primary Care Patient Safety Taxonomy9 primarily applied a single global code to an error … reports to develop a hierarchical taxonomy that describes error processes in primary care. … We then analyzed all three approaches to error classification to identify those codes and constructs … National Coordinating Council for Medication Error Reporting and Prevention.

95. Slide 1
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/cauti-sustainability.pptx
    December 01, 2015 - ERROR:#DIV/0! ERROR:#DIV/0! May 2015 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … Jun 2015 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! Jul 2015 ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! Aug 2015 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … Sep 2015 ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! Oct 2015 ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! Q2 SIR ERROR:#DIV/0!

96. Final Progress Report: Technology To Improve Medication Safety in Nursing Homes (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
    January 01, 2024 - Medication error was defined as a dose that was discrepant to the medication order. … During the analyses, medication error was considered with and without wrong-time medication error, because … had an error rate (% of medications administered in error) of 40.1%; CMT/As, 34.2%. … Table 4: Percentage of Observed Medications in Error Across Observation Periods Medication Error Type … 65% of medications observed) had an error rate of 5.6%.

97. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patient-role1.html
    September 01, 2024 - Patients and caregivers who have experienced a diagnostic error can provide a unique perspective. … goals, and concerns are too often the last to be considered. 3 , 4 The issues surrounding diagnostic error … Almost one-quarter of Americans have been affected by a diagnostic error experienced personally or by … Diagnostic process Source:  Committee on Diagnostic Error in Health Care; Board on Health Care Services … Goals for Improving Diagnosis and Reducing Diagnostic Error Source:  Committee on Diagnostic Error in

98. Medication Dashboard Data 2025 (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2025.xlsx
    January 01, 2025 - of Medication/Substance Event Safety Concern Frequency Percent Incorrect action (process failure or error … patient/family action (e.g., self-administration error) Other: Please specify 1,434 22.5% Incorrect … error) Storing 127 2.0% Incorrect patient/family action (e.g., self-administration error) Transcribing … error) Other 2,220 50.9% Incorrect patient/family action (e.g., self-administration error) Policies … error) Transcribing 673 6.9% Incorrect patient/family action (e.g., self-administration error) Unknown

99. Final Progress Report: Accountability and Health Safety – A Statewide Approach (pdf file)
    www.ahrq.gov/sites/default/files/2024-12/thorpe-rask-report.pdf
    January 01, 2024 - Key Words: Patient Safety, Error Reporting, Voluntary, Medication Error, Guideline Adherence, Error … The mean error reduction was 28% in 2002 and 34% in 2003. … , reported psychological reactions to medical error, and organizational policies on error disclosure … Disclosure of medical error: the need for moral courage. … Disclosing medical error: How much to tell?

100. The Timeline to Diagnostic Safety SIDM -Research as a Priority (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
     January 01, 2017 - Which is more error prone – intuition or normative approach? … What’s the Cost of Dx Error? Understanding the costs of dx error would motivate ….. … ” • Add these slides if Victor doesn’t cover them Diagnostic Error Error-related Harm 40,000 … – 80,000 deaths/yr The Toll of Dx Error Leape et al. … What’s the Cost �of Dx Error?