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1. Error Disclosure Training and Organizational Culture | Agency for Healthcare Research and Quality
   www.cpsi.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. Table 6: Categories of Medication Error Classification | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/patient-safety/settings/hospital/match/table-6.html
   August 01, 2012 - Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Table 6: Categories of Medication Error … , capacity to cause error NA B Error that did not reach the patient NA C Error that reached … cause harm (omissions considered to reach patient) Multivitamin was not ordered on admission D Error … Anticoagulant, such as warfarin, was ordered daily when the patient takes it every other day G Error … necessitated intervention to sustain life Anticonvulsant therapy was inadvertently omitted I Error

3. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
   www.cpsi.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.

4. Hand Hygiene Observational Audit Tracking Tool (xls file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/hand-hygiene-observational-audit-tool-tt.xlsx
   December 01, 2021 - :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR … :#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR:#N/A ERROR

5. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
   www.cpsi.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.

6. Tool 1: Readmission Data Analysis and Interpretation (xls file)
   www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool1_data_analysis_final.xlsx
   September 20, 2016 - ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! … ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0! ERROR:#DIV/0!

7. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
   www.cpsi.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

8. Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative (pdf file)
   www.cpsi.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.

9. Silence A Commentary | Agency for Healthcare Research and Quality
   www.cpsi.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 .

10. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare July 2020 Meeting Summary (pdf file)
    www.cpsi.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

11. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
    www.cpsi.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

12. Applying Human Factors to Make it Easier for Clinicians to Do Their Jobs | Agency for Healthcare Research and Quality
    www.cpsi.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

13. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
    www.cpsi.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?

14. Applying a Novel Organization Change Scale in a Multisite Patient Safety Initiative | Agency for Healthcare Research and Quality
    www.cpsi.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.

15. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
    www.cpsi.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

16. AHRQ Expands Its Repertoire to Eliminate Diagnostic Errors | Agency for Healthcare Research and Quality
    www.cpsi.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

17. Producing Accurate Clinical Quality Reports for Population Health: A Delivery System-Oriented Approach to Report Validation (pdf file)
    www.cpsi.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.

18. Learn-Facilitator-Guide (doc file)
    www.cpsi.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

19. Appendix E | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
    April 01, 2018 - Diagnostic Errors 18 408  -- Clinical Misdiagnosis 0 410  -- Diagnostic Test Interpretation Error … 2 409  -- Radiograph Interpretation Error 1 412 Discontinuities, Gaps, and Hand-Off Problems … Fellows 0 675  -- Simulators 0 669  -- Students 0 676  -- Teamwork Training 0 619 Error … Reporting and Analysis 206 625  -- Error Analysis 185 627  ---- Failure Mode Effects Analysis … 27 626  ---- Root Cause Analysis 73 688  ---- Patient Safety Indicators 3 620  -- Error

20. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.cpsi.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