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241. Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/studies/index.html
     January 01, 2024 - Diagnostic errors in hospitalized adults who died or were transferred to intensive care. … Keywords: Diagnostic Safety and Quality, Medical Errors, Hospitals, Inpatient Care, Quality of Care, … This paper describes the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study, whose aim … was to define the prevalence and underlying causes of diagnostic errors (DEs) in patients who die in … Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.

242. Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Graham.pdf
     April 14, 2004 - CU conducted a 3-year project that collected medical errors from 38 primary care practices affiliated … Process Errors Detected in Family Physician Offices (Testing Process Errors). … The ASIPS PSRS accepted clinician and staff reports of errors anonymously or confidentially. … The Testing Process Errors study involved eight family practice offices. … and skill errors, errors of commission or omission.

243. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
     December 01, 2017 - Slide 6: How Do These Errors Happen? … Errors also occur because systems frequently are not designed to catch mistakes before they reach the … on the Science of Safety Say: Science of safety training helps providers recognize that most errors … Say: Errors happen because people are fallible. … Science of safety training helps providers and others understand that the majority of errors arise from

244. OR-to-ICU Transitions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions4.html
     June 01, 2023 - a Call to Action References OR-to-ICU Handoff-Specific Contributors to Diagnostic Errors … found that death after surgery related to communication, system, diagnostic, and judgment error—all errors … significantly higher than death related to technical error. 79 Strategies To Mitigate Diagnostic Errors … These interventions resulted in fewer information omissions and errors, but the statistical quality of … This research could more explicitly explore how the HATRICC bundle could be used to reduce diagnostic errors

245. New Toolkit Can Improve Post-Surgery Complications and Enhance Patient Recovery | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/870.html
     June 01, 2023 - Grantee Profile on Kathleen Walsh, M.D., M.Sc., Highlights Work To Prevent Pediatric Medication Errors … Grantee Profile on Kathleen Walsh, M.D., M.Sc., Highlights Work To Prevent Pediatric Medication Errors … Walsh is working to prevent medication errors and adverse drug events among children, particularly those … Medication errors that occur outside the hospital can be lethal for children with chronic conditions, … Walsh has identified factors that contribute to medication errors and injuries in children with chronic

246. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-7.html
     March 01, 2022 - Diagnostic error in medicine—analysis of 583 physician-reported errors . … Accuracy of the Safer Dx Instrument to identify diagnostic errors in primary care . … Patient safety strategies targeted at diagnostic errors—a systematic review . … System-related interventions to reduce diagnostic errors: a narrative review . … Reducing diagnostic errors worldwide through diagnostic management teams .

247. Quality of Care | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/topics/quality-care.html
     Recent Research Studies Diagnostic errors in hospitalized adults who died or were transferred … Identifying and classifying diagnostic errors in acute care across hospitals: early lessons from the … Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study.

248. Resources | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/questions/resources/index.html
     November 01, 2020 - My Questions for This Visit 20 Tips To Help Prevent Medical Errors Next Steps After Your … for This Visit Prioritize questions while in the waiting room.  20 Tips to Help Prevent Medical Errors … Learn to prevent medical errors that can occur anywhere in the health care system and can involve medicines

249. Infographic Poster: Did you know...Patient safety issues in primary care are real. (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/infographicposter-final508_0.pdf
     July 12, 2018 - Annually, 1 in 20 outpatients experiences a diagnostic error 55% of patients said diagnostic errors … 9 ED admissions are related to an adverse drug event An estimated 160 million medication errors … Reduce errors and improve visit efficiency by setting the visit agenda together with Be Prepared

250. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-6.html
     September 01, 2021 - Improving Diagnostic Safety and Quality in Healthcare The Contribution of Diagnostic Errors … Prevalence of diagnostic errors as predictors of obstetric outcomes among post-natal mothers in Bungoma … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. … ‘More than words’ - interpersonal communication, cognitive bias and diagnostic errors. … Reducing diagnostic errors in medicine: what’s the goal?

251. References | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety6.html
     September 01, 2022 - Nurses are key in preventing deadly diagnostic errors in cardiovascular diseases. … Diagnosis is a team sport - partnering with allied health professionals to reduce diagnostic errors. … Diagnostic error: safe and effective communication to prevent diagnostic errors . … Communication breakdowns and diagnostic errors: a radiology perspective. … Learning from patients' experiences related to diagnostic errors is essential for progress in patient

252. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - Burns Abstract Heparin administration errors can have severe consequences for patients. … administration process through the use of a computerized protocol at a large Midwestern hospital, errors … still occurred—2.01 errors per 1,000 doses charged. … This is likely to lead to errors, either in the conversion of one unit of measurement to the other … It is likely that inexperience of this kind would make errors more likely to occur.

253. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (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-Mistry_114.pdf
     May 05, 2008 - Introduction Medical errors have been recognized as a relatively common and potentially avoidable cause … We hypothesized that: (1) communication errors commonly occur during the postoperative handoff process … In health care, for example, this may involve new methods to detect medication errors. … A look into the nature and causes of human errors in the intensive care unit. … Residents’ suggestions for reducing errors in teaching hospitals.

254. Identifying Strategies to Improve Medication Safety at Home | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-xiao.html
     November 01, 2022 - Medication errors that occur at home, especially during transitions of care such as patient discharge … The preventable harms for these medication errors include adverse drug events (ADEs), unscheduled hospital … There is an increased potential for medication errors as more responsibilities of medication management … Xiao identified frequent errors that occurred during the placement of central lines or central venous

255. Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/publications/search.html?page=2
     February 01, 2021 - instance, checklists have been successful in preventing hospital-acquired infections and preventing errors … The use of checklists has also been recommended as a tool to reduce diagnostic errors. … Diagnostic errors are frequent and often have severe consequences but have received little attention … provide knowledge and recommendations to encourage HCOs to begin to identify and learn from diagnostic errors

256. Appendix C: List of Web Sites Reviewed | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyapc.html
     July 01, 2018 - Award Manitoba Institute for Patient Safety Massachusetts Coalition for the Prevention of Medical Errors … Council—Calgary, Alberta Patients are Powerful Patients.About.Com Persons United Limiting Sub standards and Errors … Care Picker Institute Picker Institute Europe Planetree Persons United Limiting Sub standards and Errors … of America Persons United Limiting Sub standards and Errors of NY Quality and Safety Education for

257. FileNewTemplate
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/teamstepps/officebasedcare/ts-obc-online-module9.pptx
     March 07, 2019 - Identify errors common to organizational change. … We then go to step five, which is called errors common to change. … Kotter identifies ways to institutionalize change and counter these errors. … Module 9 Summary In this module, you learned to: List Kotter’s Eight Steps of Change Identify errors … Identify errors common to organizational change.

258. 4. Defining Language Need and Categories for Collection | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/iomracereport/reldata4.html
     May 01, 2018 - Evidence on variations in health outcomes, medical errors, and receipt of quality health care as a function … and increased likelihood of clinical errors ( Flores et al., 2005 ; Karliner et al., 2007 ). … (It should be noted that, although research has documented a variety of interpretation errors during … assessments, the clinical significance of such errors has not been well characterized.) … Elderkin-Thompson and colleagues also found interpretation errors in more than 50 percent of videotaped

259. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (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-Webster_76.pdf
     July 18, 2008 - International taxonomy of medical errors in primary care-Version 2. … A preliminary taxonomy of medical errors in family practice. … Preventing medication errors: Quality chasm series. … Strategies to reduce medication errors in ambulatory practice. … EPITOME program educates patient to help reduce medication errors.

260. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
     January 01, 2022 - , MPH*† Objectives: A lack of consensus around definitions and reporting standards for diagnostic errors … A lack of consensus around definitions and reporting standards for diagnostic errors limits the extent … Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.