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121. Risk-Based Patient Safety Metrics (pdf file)
     ce.effectivehealthcare.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 - Finally, errors can guide improvements. … If errors are the source of unsafe health care, then one needs to prevent the errors s . … All errors are recognized by the observer as errors. … In the case of errors and injuries, the previously discussed metrics are attempts to reflect all errors … In using errors and injuries as sources for identifying risk, the rates of errors and injuries are irrelevant

122. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
     January 01, 2004 - The next largest cause of errors was incorrectly written drug names. … Below that optimal level, errors decrease with the increasing workload; above it, however, errors increase … Errors today and errors tomorrow. New Engl J Med 2003 (348):2570–72. 11. … Variables associated with medication errors in pediatric emergency medicine. … medication errors, 2001.

123. Evidence in Use of Clinical Reasoning Checklists for Diagnostic Error Reduction (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/diagnostic-error-reduction.pdf
     September 04, 2020 - Conversely, checklists used for diagnostic safety seem to focus on errors of planning. … errors of planning? … Checklists to reduce diagnostic errors. … Patient safety strategies targeted at diagnostic errors: a systematic review. … Checklists to prevent diagnostic errors: a pilot randomized controlled trial.

124. Patient Safety Research in Medical Group Practices: Measurement and Data Challenges (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
     December 01, 2004 - We refer to these instances as errors. … The errors show how the process failed the patient. … and concluded that they could be classified as either process errors or knowledge/skills errors. … detecting errors. … Consequences of medical errors observed by family physicians.

125. News Media and Health Care Providers at the Crossroads of Medical Adverse Events (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
     June 05, 2008 - • Assisting health care providers in reducing medical errors. … • Developing “best practices” aimed at reducing medical errors. … Errors as an individual-level phenomenon. … Perceived Causes of Medical Errors News media professionals in Indiana believed that medical errors … Medical errors: The scope of the problem. AHRQ Pub. 00-P037.

126. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science-brief1.pdf
     April 02, 2020 - Types and origins of diagnostic errors in primary care settings. … Measuring errors and adverse events in health care. … Finding diagnostic errors in children admitted to the PICU. … The global burden of diagnostic errors in primary care. … Malpractice claims related to diagnostic errors in the hospital.

127. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
     April 02, 2020 - Types and origins of diagnostic errors in primary care settings. … Measuring errors and adverse events in health care. … Finding diagnostic errors in children admitted to the PICU. … The global burden of diagnostic errors in primary care. … Malpractice claims related to diagnostic errors in the hospital.

128. Getting Ready for Measurement: Overcoming Barriers and Taking Next Steps | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-3.html
     June 01, 2020 - Nevertheless, as the burden of diagnostic errors is increasingly recognized and as measurement strategies … to use the data already available to them to begin to detect, understand, and learn from diagnostic errors … While diagnostic errors occur across the spectrum of medical practice, measurement should be strategic … While diagnostic errors occur across the spectrum of medical practice, measurement should be strategic … implementation balance validity and yield (i.e., an estimate of the proportion of cases with diagnostic errors

129. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
     September 28, 2016 - Series Foundational Reports 1999 2001 To Err is Human: Building a Safer Health System • Medical errors … action to be completed as intended or the use of a wrong plan to achieve an aim • The majority of errors … • Errors cost $17 billion – $29 billion per year in hospitals in the US However, more recent data … . • Develop a knowledge base for learning about errors' causes and effective error prevention … • Diagnostic errors are the leading type of paid medical malpractice claims • Diagnostic errors can

130. Appendix E | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
     April 01, 2018 - Missed or Critical Lab Results 0 413 Fatigue and Sleep Deprivation 13 411 Identification Errors … -- Venous Thrombosis and Thromboembolism 0 414 Medication Safety 126 416  -- Medication Errors … /Preventable Adverse Drug Events 96 420  ---- Administration Errors 14 419  ---- Dispensing … Errors 11 448  ---- Monitoring Errors and Failures 23 417  ---- Ordering/Prescribing Errors … 6 418  ---- Transcription Errors 5 415  -- Side Effects/Adverse Drug Reactions 17 421

131. AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/cquips0802.html
     October 01, 2014 - Impact Case Studies AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors … Events AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors … June 2008 AHRQ-sponsored research on how clinical pharmacy services can reduce medication-related errors … ASHP aims to prevent medication errors, help people make the best use of medicines, and assist pharmacists … Internet Citation: AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors

132. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
     March 12, 2008 - the override mechanism and administering prior to pharmacy review increases the risk for medication errors … Numerous medication errors secondary to ADM override have been identified in the literature. … The remaining eight overrides (1.7 percent of total overrides) were a result of medication errors or … found errors in pharmacy, in nursing, and in the ADMs themselves. … Medication errors, 2nd edition. Washington, DC: APhA Publications; 2007. 3. Paparella S.

133. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
     March 11, 2005 - The errors and issues described in the cases also were of a diverse nature. … Among the published cases, the most common were diagnostic errors (27 percent), medication errors ( … Thirty-seven errors (67 percent) occurred in hospital, while 8 errors (14.5 percent) occurred in emergency … Discussion of medical errors in morbidity and mortality conferences. … A system of analyzing medical errors to improve GME curricula and programs.

134. Challenges to Real-Time Decision Support in Health Care (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
     January 01, 2007 - Such errors are more 1 likely to be committed by overconfident physicians. … Commission errors are less common than omission errors.3 The problems associated with medical errors … are associated with proportionately more morbidity than are other types of medical errors. … The importance of cognitive errors in diagnosis and strategies to minimize them. … An objective analysis of process errors in trauma resuscitation.

135. Development of a Comprehensive Medical Error Ontology (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
     June 16, 2008 - An ontology of medical errors is one approach to solving the problem. … • Capture the richness of the domain of errors and adverse events. … A preliminary taxonomy of medical errors in family practice. … A system of analyzing medical errors to improve GME curricula and programs. … Individual, practice, and system causes of errors in nursing: A taxonomy.

136. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
     May 01, 2003 - , but an incomplete review of common latent errors contributing to these events. … Barriers to acceptance of medical errors: the case for a teaching program. … Discussion of medical errors in morbidity and mortality conferences. … A system for analyzing medical errors to improve GME curricula and programs. … Why do errors occur? Ambul Outreach 2000 (Spring):16–20. 21.

137. Outpatient Medication Errors Prevalent Among Pediatric Leukemia, Lymphoma Patients | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/848.html
     January 01, 2023 - Home News Newsletter AHRQ News Now Outpatient Medication Errors … Today's Headlines: Outpatient Medication Errors Prevalent Among Pediatric Leukemia, Lymphoma Patients … Outpatient Medication Errors Prevalent Among Pediatric Leukemia, Lymphoma Patients An AHRQ-supported … of children with leukemia or lymphoma experienced adverse drug events due to outpatient medication errors … 2023 Page originally created January 2023 Internet Citation: Outpatient Medication Errors

138. The Timeline to Diagnostic Safety SIDM -Research as a Priority (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
     January 01, 2017 - George Bernard Shaw Measuring Diagnostic Errors 15 Human Factors What factors make dx easier … • ER The petri dish for diagnostic errors • Inpatients One in ten diagnoses is probably wrong. 36,000 … Dx errors are COMMON in patients with anemia, asthma, COPD CRICO - Analysis of 4519 claims related … Slide Number 25 Slide Number 26 Diagnostic errors are a significant but underappreciated challenge … BLUNT end���� SHARP end Safer Dx Framework for Measurement & Reduction Measuring Diagnostic Errors

139. Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-David_13.pdf
     March 19, 2008 - Given this need, near-miss chemotherapy ordering errors, and research that identifies the prescribing … /ordering step as a significant source of pediatric chemotherapy errors, Memorial Healthcare System … Standardized Pre-B ALL Standard Induction order form 6 errors continues. … Prevention of medication errors in the pediatric inpatient setting. … Prevention of medication errors in the pediatric inpatient setting.

140. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Childbirth: State of the Science PATIENT SAFETY e Issue Brief 6 The Contribution of Diagnostic Errors … e Issue Brief 6 The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During … ‘More than words’ - interpersonal communication, cognitive bias and diagnostic errors. … Reducing diagnostic errors in medicine: what’s the goal?