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81. Inpatient-to-Outpatient Transitions | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html
    June 01, 2023 - and uncertainty and discuss strategies to mitigate diagnostic errors and uncertainty. … Inpatient-to-Outpatient Handoff-Specific Contributors to Diagnostic Errors and Uncertainty Patients … and clinicians' diagnostic reasoning. 92 The most common contributing factors to clinical reasoning errors … Strategies To Mitigate Diagnostic Errors and Uncertainty at Inpatient-to-Outpatient Transitions The … including patients and families in the process, and improved awareness and education about diagnostic errors

82. Diagnostic Safety Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/research/grants-2022.html
    March 01, 2024 - 01 Project Aims: Develop a multidisciplinary diagnostic excellence center to address diagnostic errors … , accelerate its implementation in a large healthcare system, and evaluate its impact on diagnostic errors … Propose, prioritize, and codesign patient-centered solutions to mitigate diagnostic errors. … Carry out a comprehensive program evaluation, including analysis of rates of diagnostic errors and process … and outpatient) to improve patient/family and clinician communication and experience and to reduce errors

83. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (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-Neuspiel_43.pdf
    March 05, 2008 - Results: In the first year, 80 errors were reported, compared with only 5 errors reported during the … reported plus unreported errors. … Preventing medication errors. … Potential medication dosing errors in outpatient pediatrics. … Learning from errors in ambulatory pediatrics.

84. Medication Error Reporting Systems: Challenges, Lessons, Future Direction (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/cousins-report.pdf
    January 01, 2024 - Key Words: medication errors, reporting systems, patient safety, MEDMARX® Section 2. … and patterns of errors that identify systemic vulnerabilities affecting healthcare organizations. … The IOM targeted medication errors as an important focus for prevention efforts. … As one important strategy for reducing medical errors, the IOM called for mandatory error reporting … Voluntary reporting of medication errors. Am J Health-Syst Pharm. 2002; 59(23):2326-2328. 6.

85. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wakefield2.pdf
    January 01, 2003 - medication errors are not reported; and the estimated percentage of medication errors actually reported … Although errors can occur during the prescribing and dispensing phases, the MAE survey focuses on errors … medication administration errors occur. … These are to (1) detect errors; (2) estimate the frequency of specific errors; (3) assess the effects … Conclusion When medication errors are not reported, the potential to avoid future preventable errors

86. Research Agenda | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-4.html
    September 01, 2021 - Improving Diagnostic Safety and Quality in Healthcare The Contribution of Diagnostic Errors … including bias, that contribute to diagnostic error, including missed or delayed diagnosis. 19 System errors … Response Cognitive Errors Significant evidence exists to suggest that providers may be affected by … underlying cognitive errors. … Determine impact of various cognitive errors (e.g., implicit bias, anchoring, confirmation, knowledge

87. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.html
    June 01, 2023 - Although many Americans describe having heard about “medical errors” in the media, 15 only about half … These types of mistakes are called medical errors. 16 This definition is clearly worded and coherent … In hospital settings, this shift in terminology from mistakes/errors to feeling safe roughly doubled … Framing experiences in terms of “mistakes” is more approachable than framing as “diagnostic errors,” … The literature on medical errors documents that the long-term harms associated with adverse events are

88. Improving Patient Safety Systems for Limited-English-Proficient (LEP) Patients: A Guide for Hospitals | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
    December 01, 2012 - Improve Reporting of Medical Errors for LEP Patients. … Address Root Causes To Prevent Medical Errors Among LEP Patients. … Ineffective or improper use of medications or serious medication errors. … Improve Reporting of Medical Errors for LEP Patients. … Address Root Causes To Prevent Medical Errors Among LEP Patients.

89. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/tools/index.html
    March 01, 2024 - Healthcare Tools To Improve Diagnostic Safety AHRQ tools to reduce diagnostic errors … Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit aims to assist primary care practice teams … with a systematic approach to reduce diagnostic errors among children in three important areas: elevated … through the measurement, screening, recognition, diagnosis, follow-up, and reduction of diagnostic errors

90. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
    April 27, 2022 - Patient Focus Five studies explored patient reports of diagnostic errors. … Types and origins of diagnostic errors in primary care settings. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Malpractice claims related to diagnostic errors in the hospital. … Diagnostic errors in medicine: a case of neglect.

91. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-patient-experience-vol2.pdf
    July 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 … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Views of practicing physicians and the public on medical errors. … Americans’ Experiences With Medical Errors and Views on Patient Safety.

92. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-psychological-safety.pdf
    September 01, 2023 - Publication No. 23-0040-6-EF. 1 e Learning From Diagnostic Errors Diagnostic errors are both frequent … The goal of reporting and analyzing errors should be to promote insight, create solutions, and enable … 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.

93. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schiff.pdf
    January 01, 2005 - Diagnosis errors are challenging to detect and dissect. … malpractice claims revealed that diagnosis errors far outnumber medication errors as a cause of claims … Diagnosing Diagnosis Errors 257 T ab le 1 . … Unsuspected additional errors also emerge. … Diagnosis* Errors A B C D E F G Diagnosing Diagnosis Errors 265 Clinician assessment

94. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (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-November_45.pdf
    January 01, 2007 - Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology Physician-Reported … Adverse Events and Medical Errors in Obstetrics and Gynecology Martin November, MD, MBA; Lucy Chie … They are intimately aware of impediments to care or errors in management. … Although serious AEs are infrequently related to medical errors, relatively little is known about errors … Detection of errors by attending physicians on a general medicine service.

95. Introduction | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/probabilistic-thinking1.html
    September 01, 2022 - Diagnostic Pathway Future Vision for Probabilistic Diagnostic Decisions References Errors … Most patients will experience diagnostic errors in their lifetime. 1 Many diagnostic errors result from … probability. 3 Thus, more accurate execution of probability-based diagnosis is needed to reduce diagnostic errors … evidence-based methods for training on probabilistic thinking could improve diagnostic accuracy and reduce errors

96. Improving the Safety of Diagnosis and Therapy in the Inpatient Setting | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
    February 01, 2024 - Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study . … Providers' and Patients' Perspectives on Diagnostic Errors in the Acute Care Setting . … Analyzing diagnostic errors in the acute setting: a process-driven approach . … design and development of a diagnostic time-out to address diagnostic errors in acute care . … Analyzing diagnostic errors in the acute setting: a process-driven approach.

97. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
    June 01, 2023 - 01 Project Aims: Develop a multidisciplinary diagnostic excellence center to address diagnostic errors … , accelerate its implementation in a large healthcare system, and evaluate its impact on diagnostic errors … Propose, prioritize, and codesign patient-centered solutions to mitigate diagnostic errors. … Carry out a comprehensive program evaluation, including analysis of rates of diagnostic errors and process … and outpatient) to improve patient/family and clinician communication and experience and to reduce errors

98. The Impact of Personal Digital Assistant Devices on Medication Safety 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/vol3/Galt.pdf
    January 01, 2005 - Prescribing errors This paper reports on errors observed by evaluation of the face of a prescription … , including legibility errors, errors of omission, errors of commission, and errors of interpretation … The frequency of medication errors was determined by counting the total number of errors attributed … Impact of PDA use on prescribing errors The frequency of medication errors was compared between pre- … Impact of PDA on prescriber medication errors The results of the impact of PDA use on prescribing errors

99. References | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses6.html
    August 01, 2022 - Diagnostic errors. Acad Emerg Med. 2002;9(7):740-750. doi: 10.1197/aemj.9.7.740 . … Diagnostic Errors in the Emergency Department: A Systematic Review. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Changes in medical errors after implementation of a handoff program. … The importance of cognitive errors in diagnosis and strategies to minimize them.

100. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (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-Maddox_38.pdf
     March 26, 2008 - In working to reduce the frequency of medication errors, first priority must be to prevent those errors … IV medication infusion errors are widespread. … • Increase documentation of detected/prevented errors, specifically, types of errors; where/when … Focus on highest risk errors. … Identifying and averting errors that have the highest risk—i.e., IV administration errors—have an immediate