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1. Medical Errors | Agency for Healthcare Research and Quality
   www.ahrq.gov/topics/medical-errors.html
   Topic: Medical Errors Medical errors can occur anywhere in the health care system--in hospitals, clinics … Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. … sponsored hundreds of patient safety research and implementation projects to prevent and reduce medical errors

2. Introduction to Diagnostic Errors | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load1.html
   May 01, 2024 - Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors … Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors … Cognitive Load A Future Vision for Better Diagnostic Outcomes References Diagnostic errors … published in 2015, continued the patient safety discussion with a focus on the impact of diagnostic errors … This report suggested that diagnostic errors may contribute to 10 percent of all patient deaths.

3. Learning from Errors in Ambulatory Pediatrics (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
   February 01, 2004 - Learning from Errors in Ambulatory Pediatrics 355 Learning from Errors in Ambulatory Pediatrics … Web-based tool for reporting errors; (2) identify the types and range of errors; and (3) identify errors … for reporting errors; (2) identified the type and range of errors; and (3) identified errors that can … Errors in the medical treatment domain were most frequent (38 percent) followed by administrative errors … Of the errors within the medical treatment domain (Table 4), 84 percent were medication errors.

4. Clinical Inertia and Outpatient Medical Errors (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
   January 01, 2003 - Clinical Inertia and Outpatient Medical Errors 293 Clinical Inertia and Outpatient Medical Errors … development of specific interventions to reduce it may be a productive strategy to reduce passive errors … Introduction The contribution of medical errors to adverse clinical outcomes is well documented in … thus far have focused on errors related to inappropriate use or misuse of various therapies. … Medication errors observed in 36 health care facilities.

5. Learning From Diagnostic Errors | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-1.html
   September 01, 2023 - Clinician Psychological Safety in Reporting and Discussing Diagnostic Error Learning From Diagnostic Errors … 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 … Safety and Organizational Safety Culture Related to Diagnosis References Diagnostic errors … malpractice cases. 1 We do not have systematic and rigorous ways to define and enumerate diagnostic errors

6. Diagnostic Error in the Testing Process | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship4.html
   August 01, 2024 - Implementation Opportunities and Challenges Ahead Conclusion References Diagnostic errors … process with multiple structural and systemic components, a simpler way to conceptualize diagnostic errors … refer to problems with test selection, ordering, and specimen collection. 10 Often, such errors reflect … Preanalytic errors may also result from specimen mishandling; for instance, contamination of specimens … , including inadequate specimens and contamination. 30 Analytic errors refer to problems performing a

7. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
   January 01, 2003 - Do Transient Working Conditions Trigger Medical Errors? … errors) through this system. … Errors that reached the patient as well as near-miss errors or errors that were caught before they reached … Both medication errors and procedural errors, such as performing the wrong test on a patient, were included … errors in a district general hospital.

8. Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors | Agency for Healthcare Research and Quality
   www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-3.html
   September 01, 2023 - Discussing Diagnostic Error Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors … 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 … Questions about diagnostic errors challenge their sense of competency and can undermine confidence. … clinicians receive little feedback from other providers or from different care settings, so many diagnostic errors

9. Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery | Agency for Healthcare Research and Quality
   www.ahrq.gov/patient-safety/resources/learning-lab/anesthesia-medication-long-desc.html
   January 01, 2025 - Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery Principal Investigator … Period: 09/30/18-07/31/23 Description: This lab’s overarching goal was to reduce anesthesia medication errors … Medication errors, critical incidents, adverse drug events, and more: examining patient safety-related … Understanding the limitations of incident reporting in medication errors. … Final Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery.

10. Preventing Vaccine Administration Errors​: A Primer for Healthcare Workers | Agency for Healthcare Research and Quality
    www.ahrq.gov/nursing-home/resources/preventing-vaccine-errors.html
    July 01, 2022 - Preventing Vaccine Administration Errors​: A Primer for Healthcare Workers Resource: Preventing … Vaccine Administration Errors​: A Primer for Healthcare Workers ​This 30-minute course reviews best

11. A Conceptual Model for Disclosure of Medical Errors (pdf file)
    www.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.

12. The Use of Surgical Simulators to Reduce Errors (pdf file)
    www.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.

13. Research on Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/research/index.html
    November 01, 2024 - AHRQ funds research to better understand how diagnostic errors happen and what can be done to prevent … Pediatricians self-report an appreciable number of diagnostic errors . … AHRQ has awarded 4 grants that will more precisely define the scope of diagnostic errors. … Understanding what contributes to these errors. … Learning more about the link between diagnostic errors and outcomes, including adverse events.

14. Final Progress Report: How Do Consumers View the Risks of Medical Errors? (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
    January 01, 2024 - result from hospital medical errors. … The set of errors began with four general errors (e.g., “a medical error that occurs during surgery” … Greater worry about medical errors was associated with greater vulnerability to errors (older age and … from medical errors and rated likelihood of medical errors. … Perceived risks of medical errors.

15. Diagnostic Safety Grants Awarded in FY 2019 | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/research/grants-2019.html
    March 01, 2024 - year 2019 for AHRQ to initiate a research agenda to understand and solve the problem of diagnostic errors … In 2019, AHRQ awarded the four grants below that will more precisely define the scope of diagnostic errors … University of California, San Francisco Project Aims: To determine the incidence of diagnostic errors … data with data from Vizient to determine which specific factors contribute to risks for diagnostic errors … , and to use risk estimates to calculate incidence and impact of factors contributing to those errors

16. Final Progress Report: Prescribing Errors in Ambulatory Pediatric Care (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/basco-report.pdf
    January 01, 2024 - We identified 43 true LASA errors. … Scope: C-1 Background: Among pediatric medication errors, look-alike, sound-alike (LASA) errors have … outpatient settings suggests that the frequencies of LASA errors may be much lower than dosing errors … than LASA errors based on our estimates. … Implications: Identifying either LASA substitution errors or dosing errors may be akin to "finding a

17. Introduction | Agency for Healthcare Research and Quality
    www.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

18. Final Progress Report: Enhancing the Disclosure Of Medical Errors to Patients (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/gallagher4-report.pdf
    January 01, 2024 - patients about errors. … minor errors. … We found that most respondents had been involved in errors. … We concluded that pediatricians are willing to report errors to hospitals and disclose errors to patients … patients, litigious families, or minor errors.

19. Grants to Enable Diagnostic Excellence | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
    January 01, 2021 - year 2019 for AHRQ to initiate a research agenda to understand and solve the problem of diagnostic errors … In 2019, AHRQ awarded the four grants below that will more precisely define the scope of diagnostic errors … University of California, San Francisco Project Aims: To determine the incidence of diagnostic errors … data with data from Vizient to determine which specific factors contribute to risks for diagnostic errors … , and to use risk estimates to calculate incidence and impact of factors contributing to those errors

20. 1. Introduction | Agency for Healthcare Research and Quality
    www.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