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161. Diagnostic error in mental health: a review (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-mental-health-bmjqs.pdf
     April 15, 2024 - ABSTRACT Diagnostic errors are associated with patient harm and suboptimal outcomes. … Interventions to reduce diagnostic errors in mental health need further development. … Identifying psychiatric diagnostic errors with the safer DX instrument. … Toward understanding errors in inpatient psychiatry: a qualitative inquiry. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

162. Breakout Session: Use of Data and Measurement in Improving Diagnostic Safety (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/brady-summit2016-breakout.pdf
     September 28, 2016 - Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses … ► Health Care professional societies should identify opportunities to reduce diagnostic errors in … and medical liability system that facilitates improved diagnosis through learning from diagnostic errors … environment that facilitates the timely identification, disclosure, and learning from diagnostic errors … errors ► Monitor progress in reducing diagnostic errors Measurement Study Example Hospital Admission

163. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - The majority of errors that occur are considered “near misses”—errors that could have caused harm to … Unfortunately, a small portion of errors do result in an “adverse event”—an injury caused by medical … Events relating to medication errors Medication related errors are one of the most common types of … While not all medication errors result in harm, those that do can be costly. … These types of simulation training can be quite helpful in minimizing transition errors.

164. Prologue: Technology and Medication Safety (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-Prologue_Grady_Vol4.pdf
     July 25, 2008 - We are already using health IT in a number of ways: to help prevent medical errors, including adverse … Underuse, overuse, adverse events, and medical errors associated with medications can cause serious … Medication errors are a frequent cause of adverse drug events, and they can occur at any point in the … They describe systems to detect potential errors, prevent the dispensing of inappropriate medications … One group of authors examined the feasibility of detecting medication errors through self-observation

165. Toolkit to Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/ambulatory-care/safe-transitions.html
     December 01, 2017 - from one ambulatory care facility clinician to another are especially vulnerable to patient safety errors … This toolkit is designed to help staff actively engage patients and their care partners to prevent errors … The toolkit is designed to help staff actively engage patients and their care partners to prevent errors

166. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
     January 01, 2003 - An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors 39 An Analysis … of Nurses’ Cognitive Work: A New Perspective for Understanding Medical Errors Patricia Potter, … nature of nurses’ work and the relationship interruptions and cognitive load may have on omissions and errors … Introduction The occurrence of medical errors within the acute care environment, as reported in To … Individual, practice and system causes of errors in nursing: a taxonomy.

167. Using Patient Input to Improve Diagnostic Safety | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-bell.html
     March 01, 2022 - Efforts to identify the nature of diagnostic errors and how to prevent them have come a long way in just … “The traditional tools  and measures to identify diagnostic errors were developed and used by clinicians … Diagnostic errors occur in part because diagnosis itself is a multi-layered process, potentially involving … Documentation errors occur frequently, with about one in five patients reporting a perceived serious … After analyzing more than 2,000 patient-reported errors from 25,000 respondents, researchers identified

168. Federal Interagency Workgroup on Improving Diagnostic Safety--March Meeting Summary (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
     March 08, 2019 - a strategy and framework for healthcare organizations to measure, analyze, and reduce diagnostic errors … DOD • Deep-dive analysis of treatment delays that result in significant errors. … • Contributions of human factors to errors that have led to harm. … The Society to Improve Diagnosis in Medicine will hold its annual Diagnostic Errors in Medicine meeting

169. 1. Introduction | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state1.html
     January 01, 2024 - Interview Guide Diagnostic errors have emerged as a major patient safety concern. … Research has shown unacceptable rates of diagnostic errors in acute care, ambulatory care, and emergency … diagnostic error. 2 These estimates are consistent with data from the general public about diagnostic errors … Findings have several implications for future resource investments to reduce harm from diagnostic errors

170. Diagnostic Safety as a Challenge for Healthcare Leadership | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-1.html
     June 01, 2021 - This care includes addressing both established and emerging safety concerns, such as diagnostic errors … Errors involve common conditions and nearly half of them have potential for patient harm. … The nature and magnitude of diagnostic errors and their tangible associated costs are drawing the attention … healthcare-associated infections, or HAIs), 3 in addition to the moral imperative for preventing diagnostic errors … with effort, effective strategies, and input from others. 7 Confronting the challenge of diagnostic errors

171. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (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-Simmons_66.pdf
     April 03, 2008 - Anderson Cancer Center to 1 facilitate a proactive approach to preventing errors. … • Providing definitions and examples of actual and potential errors. … One hospital’s journey toward reducing medication errors. … Perceived barriers in reporting medication administration errors. … Reduction of adverse drug events and medication errors in a community hospital setting.

172. Post-fielding Surveillance of a Guideline-based Decision Support System (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
     January 01, 2004 - , should undergo similar predeployment testing to prevent introduction of new errors. … Analysis of clinician-user feedback facilitated rapid detection and correction of such errors. … Introduction ALL technology introduces new errors, even when its sole purpose is to prevent errors … There were no additional programming, logic, or treatment errors identified by study providers. … Reducing the frequency of errors in medicine using information technology.

173. Making a Case for Organizational Change in Patient Safety Initiatives (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Ramanujam.pdf
     January 01, 2003 - These complex processes, themselves vulnerable to errors, are overlaid on a health care culture that … Implementing this strategy will require several changes: redesigning work processes to make errors more … context where practitioners feel psychologically safe about discussing their errors and seeking help … Employees at the point of care must acquire the capabilities to analyze errors locally and implement … same errors continued to occur, so they stopped reporting.

174. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - ICU-Specific Contributors to Diagnostic Errors and Uncertainty Due to the high complexity and acuity … information, and both cognitive failures and system-based failures, all of which can lead to diagnostic errors … ICU-to-Ward Handoff-Specific Contributors to Diagnostic Errors and Uncertainty When transitioning from … patient transitioning from the ICU to a ward. 70 , 71 Further research should examine how diagnostic errors … transitions of care. 30 In conclusion, the ICU-to-ward transition is a high-risk time for diagnostic errors

175. Advances in Patient Safety: New Directions and Alternative Approaches | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
     July 01, 2022 - The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis … Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (   PDF , 109 KB ) … Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS … Using Data Mining to Predict Errors in Chronic Disease Care (   PDF , 660 KB ) Ryan M. … Using Home Visits to Understand Medication Errors in Children (   PDF , 622 KB ) Kathleen E.

176. Improving Safety for Patients with Limited English Proficiency: TeamSTEPPS
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2013-materials/teamstepps-monthly-webinar-oct2013.pptx
     January 01, 2013 - LEP and culturally diverse patients Present five key strategies for improving detection of medical errors … Culture for Safety of Diverse Patient Populations Adapt Current Systems to Better Identify Medical Errors … Among LEP Patients Improve Reporting of Medical Errors for LEP Patients Routinely Monitor Patient Safety … for LEP Patients Address Root Causes to Prevent Medical Errors Among LEP Patients TEAMSTEPPS 05.2 … Errors in medical interpretation and their potential clinical consequences in pediatric encounters.

177. Preface | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/advances/preface.html
     July 01, 2022 - 1999 report, To Err Is Human: Building a Safer Health System , galvanized action to reduce medical errors … , there was already an emerging body of knowledge on why errors occur and how to prevent them. … Now, 5 years after the release of To Err Is Human , the evidence on preventing medical errors and the

178. Error Producing Conditions in the Intensive Care Unit (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - Among the areas where errors occur frequently is the intensive care unit (ICU). … to errors in the ICU. … The first section focused on errors in the ICU in general. … making errors”; and others. … Causes of prescribing errors in hospital inpatients: A prospective study.

179. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
     March 01, 2002 - , which include errors in the process of ordering or delivering a medication and errors of omission … and pharmacists reduce medication errors. … Relationship between medication errors and adverse drug events. … ASHP Statement on Reporting Medical Errors [ASHP Reports]. … Medication errors observed in 36 health care facilities.

180. Executive Summary | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … broad language, rather than trying to give patients and families more precise definitions of “medical errors … and family conceptions of adverse events do not always conform to clinical definitions of diagnostic errors