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1. Error Disclosure Training and Organizational Culture | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/patient-safety/reports/liability/etchegaray.html
   August 01, 2017 - vs. 41 percent), serious error disclosure (79 percent vs. 58 percent), trust-based error disclosure … , minor error (i.e., error that causes harm that is neither permanent nor life-threatening) disclosure … disclose this error. … The improvements in minor error disclosure culture and serious error disclosure culture observed between … Minor Error Disclosure Serious Error Disclosure Error Disclosure Trust Safety Culture Teamwork

2. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
   April 27, 2022 - Three studies operationalized error using existing definitions only. … in published peer-reviewed diagnostic error research?” … error work is to improve the care of patients.” … Clinician survey on diagnostic error Clinician survey on diagnostic error Accuracy Timeliness … Patients’ perspectives of diagnostic error: a qualitative study.

3. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
   January 01, 2003 - First, by definition, recognition that an error has occurred means that the error happened some time … Because of this, recognition that an error has occurred is very difficult.20 Second, even if an error … again, rather than focusing on the underlying cause of the error.40 Nurses do not see error reporting … • Nurses do not recognize an error occurred. • Medication error is not clearly defined. … Medication Administration Error Reporting Survey 489 46.

4. Diy-Run-Chart-Tool (xls file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/diy-run-chart-tool.xlsx
   June 21, 2021 - :#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

5. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
   January 01, 2024 - As the lead Federal agency investing in research to improve diagnostic safety and reduce diagnostic error … MB) Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error … Emergency Departments  ( PDF , 3 MB) Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error … Defining diagnostic error: a scoping review to assess the impact of the national academies' report improving

6. Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/West.pdf
   September 01, 2005 - Pace Abstract Background and objectives: Approaches to translating medical error information into … (1) develop an initial conceptual framework for depicting specific clinical processes at risk for error … In general, Learning Groups served to: • Help interpret error data. … upon the frequency of error, degree of harm associated with the error, practice culture, and anticipated … Eliminating unnecessary steps within processes can reduce error and improve efficiency.

7. Silence A Commentary | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/patient-safety/reports/liability/silence.html
   August 01, 2017 - This is what it feels like when you lose a loved one to a medical error. … , a systems error, or both. … In some cases, it may be a provider or team that takes responsibility for the error; in other cases, … In the past, patients experienced only silence and abandonment after a medical error. … The many faces of error disclosure: A common set of elements and a definition .

8. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
   www.cahps.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-072320.pdf
   November 06, 2020 - PSNet: Published a primer on 7/22/20 called COVID-19 and Dx Error. … grant=R01+HS27614-01 https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error … https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error https://www.cdc.gov … Recently Published Diagnostic Safety Relevant Papers: o Reducing the Risk of Diagnostic Error in the … www.journalofhospitalmedicine.com/jhospmed/article/222266/hospital-medicine/reducing-risk-diagnostic-error-covid

9. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
   www.cahps.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
   June 01, 2023 - to create a taxonomy to classify the contribution of electronic health records (EHRs) to diagnostic error … Use data gathered from error reporting to facilitate implementation of a multiparameter strategy that … DECODE: Diagnostic Excellence Center on Diagnostic Error Principal Investigators: Ramin Khorasani … Evaluate the structure, process, and outcome effects of human-centered solutions on diagnostic error … Develop site-level and groupwide benchmarking reports of error rates, diagnostic processes, and diagnostic

10. Applying Human Factors to Make it Easier for Clinicians to Do Their Jobs | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/funding/grantee-profiles/grtprofile-miller.html
    August 01, 2022 - health information technology,  and other factors that can increase a woman’s risk of a CVD diagnostic error … The potential for a CVD diagnostic error can begin as soon as women describe their symptoms, according … team is studying the role of the ambulatory care environment in elevating the risk of a CVD diagnostic error … that clinicians use to help them predict CVD risk itself can be a contributing factor to diagnostic error … a human factors engineering approach cannot identify an overall formula for reducing CVD diagnostic error

11. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/reports/liability/crane.html
    August 01, 2017 - The primary error was defined as “the breakdown in process, or knowledge/skill deficit that led to the … Each reported error was coded with just one primary error but with up to four additional associated or … reporting, and the psychological barriers to admitting involvement in an error in patient care. … "Every error counts": a web-based incident reporting and learning system for general practice. … Does error and adverse event reporting by physicians and nurses differ?

12. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/patient-safety/reports/liability/brock.html
    August 01, 2017 - Interventions to improve skills around error disclosure constitute a good test of the OCS; successful … The second component of the intervention focused on a culture of transparency around error disclosure … 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.

13. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
    October 01, 2021 - The initial diagnosis, while not correct, was not necessarily due to an error. … Talking about error can lead to perceptions that inadvertently suggest blame, but it’s important to remember … An example of a common type of cognitive error that can lead to a diagnostic error is called recency … Oftentimes a diagnostic error is the result of a combination of cognitive and systemic issues. … quickly to keep up with patient care when the ED is short-staffed might be more apt to make a thinking error

14. AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/news/blog/ahrqviews/eliminate-diagnostic-errors.html
    August 01, 2022 - many Americans have experienced the health-related consequences and anxieties that follow a diagnostic error … One in 20 adults annually experiences a diagnostic error in outpatient settings. … These centers will develop expertise in at least one of four areas: error detection and prevention, resilience

15. Producing Accurate Clinical Quality Reports for Population Health: A Delivery System-Oriented Approach to Report Validation (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/ehr-reports.pdf
    March 01, 2016 - .........14 Case Study..............................................................14 Sources of Error … ....15 Inclusion Errors ............................................................16 Inclusion Error … One by one, the Medical Director and her DBA figured out and corrected the cause of each error. … Once an error is found, it is important to document the information both by the nature of the error … Inclusion Error Examples 1.

16. Final report: To Quantify the Impact of the Existing vs. Enhanced Work Configuration of Radiation Therapy Technicians on Workload, Situation Awareness, and Performance during Pretreatment QA Tasks (pdf file)
    www.cahps.ahrq.gov/sites/default/files/2024-01/mosaly-report.pdf
    January 01, 2024 - Table 1: Description of simulated scenarios and corresponding embedded error in each scenario Scenario … Description Embedded Error 1. … The error detection and procedural compliance was calculated as the average score of error detection … and/or missing information, 1 denotes proper documentation of error and/or missing information). … An alpha of 0.05 was used for an acceptable type-I error for statistical significance.

17. Learn-Facilitator-Guide (doc file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/learn/learn-facilitator-guide.docx
    May 01, 2017 - Can you identify examples of human error in your unit or hospital? … Slide 15 SAY: To improve outcomes, human error, at-risk behavior, and reckless behavior each should … Human error is a product of both system design and behavioral choices. … Human error can be managed through changes in processes, procedures, training, system design, or work … The proper management approach is to console providers who have committed a human error and to ensure

18. Chapter 2: Five Key Recommendations To Improve Patient Safety for LEP Patients | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/health-literacy/professional-training/lepguide/chapter2.html
    September 01, 2020 - They do not receive training on what constitutes an error or a near miss, or on how to report these when … It focuses on removing stigma associated with medical errors to allow an open environment of error reporting … Use medical error reporting as a learning tool for greater hospital staff understanding, and expand the … to better understand root causes and high-risk scenarios, and develop strategies for improvement and error

19. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.cahps.ahrq.gov/diagnostic-safety/tools/index.html
    March 01, 2024 - primary care offices consistently show that the process for managing tests is a significant source of error … a checklist and other resources to help patients understand what they can to do prevent diagnostic error … Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error

20. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
    www.cahps.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
    July 05, 2023 - Thus, capitation and payer integration lie to the left of direct error penalties in . … What is Diagnostic Error?: Improvediagnosis.org. diagnostic-error/ [Accessed 26 Jul 2022]. 6. … Payment innovations to improve diagnostic accuracy and reduce diagnostic error. … Interventions targeted at reducing diagnostic error: systematic review. … Diagnostic error inmedicine: analysis of 583 physician-reported errors.