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1. Error Disclosure Training and Organizational Culture | Agency for Healthcare Research and Quality
   www.talkingquality.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. Hand Hygiene Observational Audit Tracking Tool (xls file)
   www.talkingquality.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

3. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
   www.talkingquality.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

4. Just Culture Webcast Closing (pdf file)
   www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-3-closing.pdf
   June 01, 2017 - Just Culture Webcast Closing Updating the Hospital Survey and Nonpunitive Response to Error • HSOPS … and a pilot study – Version 2.0 to be released in early 2018 – Revising the Nonpunitive Response to Error … composite to reflect Just Culture concepts 31 Nonpunitive Response to Error Response to Error … quality-patient-safety/patientsafetyculture/index.html Updating the Hospital Survey and NonpunitiveResponse to Error

5. Action Planning for the SOPS Surveys-Results (pdf file)
   www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/04-yount-sops-action-planning-tool.pdf
   June 01, 2019 - Events Reported 65 Communication Openness 64 Teamwork Across Units 62 Feedback & Communication About Error … 62 Staffing 50 Nonpunitive Response to Error 41 Handoffs & Transitions 37 33 34 Comparing to the … 62 69 69 Staffing 50 53 55 Nonpunitive Response to Error 41 47 50 Handoffs & Transitions 37 48 49 … 62 69 69 66 Staffing 50 53 55 56 Nonpunitive Response to Error 41 47 50 30 Handoffs & Transitions 37 … 62 69 69 66 Staffing 50 53 55 56 Nonpunitive Response to Error 41 47 50 30 Handoffs & Transitions 37

6. Just Culture Webcast Intro (pdf file)
   www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/hospwebinar/just-culture-webcast-1-intro.pdf
   November 09, 2016 - Feedback & communication about error – 3. Frequency of event reporting – 4. … Nonpunitive response to error – 7. Organizational learning--continuous improvement – 8. … Nonpunitive Response to Error Survey Items – Staff feel like their mistakes are held against them. … Lowest Performing Composite Results –2016 AHRQ Comparative Database Defining Nonpunitive Response to Error … Nonpunitive Response to Error Survey Items

7. Silence A Commentary | Agency for Healthcare Research and Quality
   www.talkingquality.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.talkingquality.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.talkingquality.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. SOPS Nursing Home Survey: What You Need To Know - Nicholas Castle, Ph.D., M.H.A., FGSA (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
    January 01, 2006 - between 44,000 and 98,000 individuals die each year as a result of medical mistakes. 17 Medical Error … Human Error 1990 Patient Safety Culture in Nursing Homes • Safety culture scores are lower on average … 25 The Importance of Safety Culture in Nursing Homes The Importance of Safety Culture Medical Error

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

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

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

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

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

16. 20 Tips To Help Prevent Medical Errors: Patient Fact Sheet | Agency for Healthcare Research and Quality
    www.talkingquality.ahrq.gov/questions/resources/20-tips.html
    November 01, 2020 - One in seven Medicare patients in hospitals experience a medical error.

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

19. Understanding SOPS Surveys: A Primer for New Users (Webcast) - Gray (Overview) (pdf file)
    www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-SOPS_101_Webcast-GRAY-Overview.pdf
    March 03, 2020 - Safety Culture Assessed Across SOPS Surveys • Teamwork • Communication Openness • Communication About Error … • Organizational Learning—Continuous improvement • Response to Error • Staffing • Supervisor/Management … in medical offices supports accurate diagnoses ► Assist in identifying processes and sources of error

20. Learn-Facilitator-Guide (doc file)
    www.talkingquality.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