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41. Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study (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-Lynch_37.pdf
    March 21, 2008 - Errors were identified in 84 of the cases (34.1 percent). … Not all errors result in harm to a patient; some errors are discovered before harm takes place. … Errors were identified for 84 of the medication management encounters (34.1 percent); 67 errors (80 … percent) were chart documentation errors. … The chart review identified 66 additional errors, mostly documentation errors; 16 of the errors (19.1

42. The Potential of Psychological Safety and Organizational Safety Culture To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-2.html
    September 01, 2023 - Clinician Psychological Safety in Reporting and Discussing Diagnostic Error Learning From Diagnostic Errors … Improve Diagnostic Safety Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors … concept is generally used in patient safety to encourage transparent and open discussion of hazards and errors … The goal of reporting and analyzing errors should be to promote insight, create solutions, and enable … firmly embedded in patient safety, but evidence is limited around their role in addressing diagnostic errors

43. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Pace.pdf
    January 01, 2004 - Discussion: Approaches to classifying medical errors vary widely. … errors. … , errors involving patient care outside of the office, and errors in the referral Advances in Patient … Discussion Approaches to classifying medical errors vary widely. … A preliminary taxonomy of medical errors in family practice.

44. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
    March 01, 2020 - Patient Identification Errors in the Operating Room Patient Identification Errors in the Operating … errors. … Patient Identification Errors. 2016. … One evidence review examined errors in intensive care units. … Patient Identification Errors in the Operating Room PRISMA Diagram Appendix B.

45. The Use of Surgical Simulators to Reduce Errors (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Fried.pdf
    January 01, 2003 - The Use of Surgical Simulators to Reduce Errors 165 The Use of Surgical Simulators to Reduce Errors … As with flight simulation, near miss detection capabilities anticipate potential errors before they … Some errors, such as “wrong tool choice,” were assigned simple “yes” or “no” measures. … Surgical Simulators for Reducing Errors 173 Table 1. … Surgical Simulators for Reducing Errors 177 28. Gallagher AG, Satava, RM.

46. A Conceptual Model for Disclosure of Medical Errors (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
    January 01, 2004 - Results: All groups believed that errors should be disclosed. … And medical errors, we could dialogue with in a pretty decent way.” … of Medical Errors 493 more common and less frequently revealed. … Patients’ and physicians’ attitudes regarding the disclosure of medical errors. … A study of the ethical duty of physicians to disclose errors.

47. Advancing Diagnostic Safety: An AHRQ Leadership Conversation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-conversation.html
    October 01, 2021 - DM: Do diagnostic errors happen often? JB: They’re more prevalent than one might think. … DM: Are all wrong diagnoses considered diagnostic errors? JB: No. … DM: Why do diagnostic errors occur in the first place? … Errors related to the way we think are called cognitive errors. … They will make it possible to avoid the high costs and human toll that diagnostic errors exact. 

48. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
    January 01, 2004 - Of the medication errors reviewed, errors resulting in permanent harm accounted for 18 percent, near-death … errors accounted for 48 percent, and errors resulting in death accounted for 23 percent of the reports … Analysis of New York Medication Errors 135 Figure 1. … This finding is not unexpected, as 90 percent of the errors involved administration of a drug (errors … The pharmacist or nurse may intercept prescribing errors and the nurse may catch dispensing errors.

49. Veinte consejos para ayudar a evitar errores médicos | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patients-consumers/care-planning/errors/20tips/20tipssp.html
    August 01, 2018 - https://www.ahrq.gov/patients-consumers/care-planning/errors/20tips/20tipssp.html  

50. Special Considerations for Measurement of Diagnostic Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-2.html
    June 01, 2020 - Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. … Valid and reliable measurement of diagnostic errors results in collective mindfulness, organizational … The Safer Dx framework underscores that diagnostic errors can emerge across multiple episodes of care … Many methods have been suggested to study diagnostic errors. 32 While most of them have been evaluated … Unknown scope and frequency of errors.

51. Improving Patient Safety Systems for Patients With Limited English Proficiency | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/health-literacy/professional-training/lepguide/index.html
    September 01, 2020 - This guide focuses on how hospitals can better identify, report, monitor, and prevent medical errors … Among Patients with LEP     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 … Although the principles of patient safety and the science of preventing medical errors have evolved and … that teaches a set of team behaviors and structured communication tools designed to reduce medical errors

52. Preventing Vaccine Administration Errors​: A Primer for Healthcare Workers | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/nursing-home/resources/preventing-vaccine-errors.html
    July 01, 2022 - Home COVID-19 Action Network Resources Catalog Preventing Vaccine Administration Errors​ … Catalog News Best Practice Summaries Preventing Vaccine Administration Errors​ … : A Primer for Healthcare Workers Resource: Preventing Vaccine Administration Errors​: A Primer … Page originally created July 2022 Internet Citation: Preventing Vaccine Administration Errors​

53. ED-to-Hospital Transitions | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions2.html
    June 01, 2023 - ED-Specific Contributors to Diagnostic Challenges and to Diagnostic Errors and Uncertainty EDs are … in the ED are generally considered multifactorial. 19 In addition to being common, diagnostic errors … Second, and relatedly, early diagnostic errors can propagate other types of medical errors such as admission … . 12 , 15 ED-to-Ward Handoff-Specific Contributors to Diagnostic Errors and Uncertainty Because of … In conclusion, the ED-to-hospital transition is a high-risk time for diagnostic errors.

54. Issues With Electronic Health Records Contribute to Diagnostic Errors | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/863.html
    May 01, 2023 - Events Issues With Electronic Health Records Contribute to Diagnostic Errors … Today's Headlines: Issues With Electronic Health Records Contribute to Diagnostic Errors . … Issues With Electronic Health Records Contribute to Diagnostic Errors A majority of diagnostic errors … Of 199 diagnosis-related claims, EHRs were considered a potential contributor to diagnostic errors in … 2023 Internet Citation: Issues With Electronic Health Records Contribute to Diagnostic Errors

55. Introduction | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-2.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 … some legitimate concerns that patients and their families: Might be unaware of certain types of errors … recent years. 12,13,14,15,16,17 Investment in learning from patients’ experiences about diagnostic errors … Throughout this brief, we refer to adverse diagnostic events as “diagnostic mishaps,” “diagnostic errors

56. AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors in E.D. Patients | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/201509.html
    January 01, 2018 - Impact Case Studies AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors … Newsletter Events AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors … May 2015 AHRQ-sponsored research on how clinical pharmacy services can reduce medication-related errors … The Institute of Medicine has identified medication errors as the most common type of error in health … 2015 Internet Citation: AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors

57. Error Disclosure Training and Organizational Culture | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/etchegaray.html
    August 01, 2017 - Self‑reported likelihood to disclose errors also improved. … Patients want to know about medical errors, with virtually all patients wanting to know about errors … as opposed to minor errors. … and serious errors. … to disclosing minor errors is still lower than serious errors, suggesting that clinicians are even less

58. AHRQ’s Measure Dx Tool: Discover and Learn From Diagnostic Errors | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/newsletters/e-newsletter/831.html
    September 01, 2022 - Newsletter AHRQ News Now AHRQ’s Measure Dx Tool: Discover and Learn From Diagnostic Errors … Now Events AHRQ’s Measure Dx Tool: Discover and Learn From Diagnostic Errors … Population, 2019 ) Today's Headlines: AHRQ’s Measure Dx Tool: Discover and Learn From Diagnostic Errors … AHRQ’s Measure Dx Tool: Discover and Learn From Diagnostic Errors Despite the frequency of diagnostic … errors, clinicians and healthcare organizations seldom learn from diagnostic events due to the complexity

59. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
    July 01, 2003 - The identification and characterization of medication errors occurring in the Medical Errors Prior … Definitions of medication errors differ, depending on one’s perspective. … Even using IT to evaluate medication errors requires careful planning. … Relationship between medication errors and adverse drug events. … Reducing the frequency of errors in medicine using information technology.

60. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
    July 05, 2023 - The PRIDx framework to engage payers in reducing diagnostic errors in healthcare Mini Review Kisha … Blackall and Hardeep Singh The PRIDx framework to engage payers in reducing diagnostic errors in healthcare … Despite growing interest in the measurement and prevention of diagnostic errors, direct engagement of … Advancing the science ofmeasurement of diagnostic errors in healthcare: the Safer Dx framework. … Diagnostic error inmedicine: analysis of 583 physician-reported errors.