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61. Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: 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/vol3/West.pdf
    September 01, 2005 - errors. … and diagnostic testing errors. … These errors represent nearly 60 percent of all medical errors reported to ASIPS in which clinical harm … • Diagnostic testing errors (with a focus on lab tests): More than 50 percent of all medical errors … and identify errors immediately when they occur.

62. Using Data Mining to Predict Errors in Chronic Disease Care (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-McCabe_39.pdf
    March 28, 2008 - Using Data Mining to Predict Errors in Chronic Disease Care Using Data Mining to Predict Errors in … Errors of Omission Feedback strategies committed more errors of omission than feedforward strategies … All models committed fewer errors in the low A1c cells (feedforward strategies committed no errors). … Precision is the percentage of the actual errors among all the encounters that were classified as errors … and overpredicting errors.

63. Introduction | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions1.html
    June 01, 2023 - other providers, but also these providers may be at high risk for anchoring bias and other cognitive errors … Each transition of care has certain underlying context-specific factors contributing to diagnostic errors … Cognitive errors can include: Faulty hypothesis generation (such as failing to consider rare diseases … In addition to cognitive errors of omission and commission, communication errors may follow similar patterns … transition-specific contributors, and (3) recommended strategies to prevent and mitigate diagnostic errors

64. Final Progress Report: Auditory Perception of Drug Names: Neighborhood Effects (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-03/lambert3-report.pdf
    January 01, 2024 - One in six medication errors involves name confusion. … attributable to medical errors, but most agree that errors are a threat to patient safety.2,3 Errors … Substitution errors are more interesting, because they correspond to potentially harmful wrong-drug errors … There were 1408 substitution errors overall. … Total number (%) 1783 (14.6%) 1408 (9.66%) 1268 (9.20) 285 % of errors that were substitution errors

65. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
    January 01, 2024 - Predicting and Detecting Drug Name Confusion Errors 3.A. … Automated detection of look-alike/sound-alike medication errors. … Both studies nonetheless found scores of potential errors. … Does Tall Man lettering prevent drug name confusion errors? … How many hospital pharmacy medication dispensing errors go undetected?

66. A System to Describe and Reduce Medical Errors in Primary Care (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-Kaprielian_9.pdf
    January 01, 2007 - Errors in prescribing medication. 2. … Errors related to filing systems. 4. Errors in dispensing medications. 5. … Errors in responding to abnormal laboratory test results.8 Studies have found that most errors in … The most common issues were errors in reporting results to providers and errors in responding to results … A preliminary taxonomy of medical errors in family practice.

67. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.html
    June 01, 2023 - Perceptions of Safety and Medical Errors from Patients’ Perspectives Four past findings have relevance … They were, in fact, directly related to the hole in my new valve….No one spoke to me about the errors … A handful of population-based surveys of Americans’ experiences with medical errors document cases that … respondents believed involved diagnostic problems. 24 , 29 , 38  About half of reported medical errors … Types and prevalence of patient/family-reported diagnostic errors Type of Diagnostic Error

68. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
    March 01, 2024 - Among those patients, about 18 percent of errors caused temporary harm, permanent harm, or death. … The urgent need to reduce these errors—which include diagnoses that are either inaccurate, delayed, or … Safety Centers of Excellence are working to better characterize, understand, and measure diagnostic errors … and training; health information technology; identification, analysis, and reduction of diagnostic errors … They underscore the imperative to mitigate diagnostic errors and harm.

69. Cinco recomendaciones para recibir una mejor atención médica | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patients-consumers/care-planning/errors/5steps/cincorecsp.html
    September 01, 2014 - https://www.ahrq.gov/patients-consumers/care-planning/errors/5steps/cincorecsp.html  

70. 3. Results | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
    January 01, 2024 - Incidence and Contributing Factors This domain covers the frequency of diagnostic errors and factors … Incidence Quantifying diagnostic errors through incidence rates and other methodologies helps provide … studies have now demonstrated that diagnostic errors are frequent or harmful in different healthcare … Contributing Factors Studies show that diagnostic errors nearly always have multifaceted causes and … Burden The burden of diagnostic errors exists beyond just health outcomes.

71. References | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state-references.html
    January 01, 2024 - Types and origins of diagnostic errors in primary care settings. … A critical appraisal of AHRQ’’s ““diagnostic errors”“ report. … Finding diagnostic errors in children admitted to the PICU. … Strategies to reduce diagnostic errors: a systematic review. … Reducing diagnostic errors in primary care.

72. Health Care Simulation to Advance Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/research/findings/factsheets/errors-safety/simulproj15/index.html
    August 01, 2018 - Home Research Research Findings & Reports Fact Sheets Medical Errors … Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets Medical Errors … https://www.ahrq.gov/research/findings/factsheets/errors-safety/simulproj15/index.html  

73. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-5.html
    September 01, 2020 - validity of checklist use is high and several experts have promoted checklist use to reduce diagnostic errors … These types of errors are easily prevented by a checklist that prevents clinicians from skipping steps … Conversely, checklists used for diagnostic safety seem to focus on errors of planning. … These errors occur when the plan of an action was incorrect (e.g., due to lack of knowledge). … An important and unanswered question for diagnostic safety is whether checklists can prevent such errors

74. Establishing a Culture of Patient Safety Through a Low-tech Approach to Reducing Medication Errors (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Shaha.pdf
    May 01, 2004 - Why medication errors? … : • Interception of prescribing errors improved 30.9 percent … • Prescribing errors themselves were reduced by 31.6 percent. … Relationship between medication errors and adverse drug events. … Draft guidelines for preventing medication errors in pediatrics.

75. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
    January 01, 2024 - The proposed Aims were: Aim 1: To analyze the frequency and determinants of errors and adverse events … Among adverse events, medication errors are of particular concern because they are common, costly, and … Despite the frequency of ambulatory patient safety errors and adverse events, most efforts to study … The ASPIRE reach program sought to address this gap by studying ambulatory patient safety errors for … Third, some important patient safety errors are not amenable to EHR-based quality measurement.

76. Measure Dx: Making Diagnostic Safety Your Measurement Priority (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/MeasureDx-infographic.pdf
    July 01, 2022 - Measurement Priority Measure Dx Making Diagnostic Safety Your Measurement Priority 1 Why Diagnostic errors … experience a diagnostic error in the outpatient setting every year.a About 250,000 harmful diagnostic errors … The frequency of diagnostic errors in outpatient care: estimations from three large observational studies … Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta- analysis

77. References | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
    August 01, 2023 - Overcoming Diagnostic Errors in Medical Practice. J Pediatr . … The potential for errors in children with special health care needs. … Medication errors in the homes of children with chronic conditions. … Diagnostic Errors and Diagnostic Calibration. JAMA . … Cognitive Errors in Pediatric Emergency Medicine. Pediatr Emerg Care .

78. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
    January 01, 2024 - The global burden of diagnostic errors in primary care. … Diagnostic errors in paediatric cardiac intensive care. … Finding diagnostic errors in children admitted to the PICU. … Checklists to reduce diagnostic errors. … Reducing diagnostic errors in primary care.

79. References | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-ref.html
    September 01, 2023 - Clinician Psychological Safety in Reporting and Discussing Diagnostic Error Learning From Diagnostic Errors … Malpractice claims related to diagnostic errors in the hospital. … Voluntary electronic reporting of medical errors and adverse events. … Reflection on medical errors: a thematic analysis. Med Teach 2023 Jun 12:1-7. … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.

80. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
    January 01, 2004 - errors (28.6 to 88.9 percent), intercepted pharmacist medication errors (30.0 to 65.9 percent), and … , with the largest increases for prescribing errors (2.1 to 14.8 percent) and improper dose errors … Comparison of medication errors, adverse drug events, and intercepted errors Year Annual admission … in intercepted medication errors and physician-attributed medication errors. … Comparison of medication errors, adverse drug events, and intercepted errors Table 2.