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101. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
     www.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.

102. OR-to-ICU Transitions | Agency for Healthcare Research and Quality
     www.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

103. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
     www.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.

104. Final Progress Report: Quality Care and Error Reduction in Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
     January 01, 2024 - were limited to medication-related errors and adverse events. … This focus on medication errors is so linked to patient safety that other kinds of errors, such as those … , such as medication-related errors. … Errors, other than medication-related ones, can be difficult to recognize. … and allowed them to avoid the stigma of denoting errors.

105. Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error Evaluation and Research (DEER) Project (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
     January 01, 2025 - team to study such errors. … Medical error studies find that 10-30% (range 0.8%-56.8%) of errors are errors in diagnosis. … diagnosis errors. … Grand Round: Diagnostic errors. … Medical errors: Focusing on the problem of diagnosis errors. Medical grand rounds. St.

106. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact6.html
     July 01, 2024 - Detailed documentation enhances patient safety by reducing the risk of diagnostic errors and facilitating … However, specific knowledge about diagnostic errors within EHR documentation is limited, indicating a

107. Development and Validation of the Medication Administration Error Reporting Survey (pdf file)
     www.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

108. Making Healthcare Safer IV | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs4/index.html
     May 01, 2025 - I, II, and III have shown a positive impact of patient safety practices on the reduction of medical errors … evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors … evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors … Computerized Clinical Decision Support To Prevent Medication Errors and Adverse Drug Events (Feb. 9,

109. Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/medlist.html
     October 01, 2022 - strategy helps to improve documentation because we can see the medications and decrease medication errors … In the primary care setting, medication safety issues include prescribing errors, contraindications, … That’s at least 160 million medication errors annually .

110. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors, Volume 2: Eliciting Patient Narratives (pdf file)
     www.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.

111. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
     August 01, 2022 - Thus, it is no wonder that diagnostic errors occur. … of distributed cognition would be a major advance in the quest to limit harm associated with these errors

112. Final Progress Report: Validation of an Innovative Approach to Error Reduction (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/blumenthal-report.pdf
     January 01, 2024 - of EDs associated with the occurrence of errors. … This study measured errors in a large sample of EDs throughout the U.S. … the occurrence of errors in EDs. … Our study may underestimate the incidence of errors in EDs. … The Determinants of Errors in Emergency Departments.

113. Final Progress Report: Malpractice Insurers’ Medical Error Surveillance and Prevention Study (MIMESPS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/studdert-report.pdf
     January 01, 2024 - We analyzed the characteristics of errors. … • Patients’ role in errors. … nature of errors. … Our findings highlight the complexity of errors, especially diagnostic errors that occur in the ambulatory … • Trainee involvement in errors.

114. Protecting Patients from Drug-Drug Medication Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-malone.html
     September 01, 2023 - Grantee Profile Protecting Patients from Drug-Drug Medication Errors Daniel C. … DDI alerts and shared decision-making resources, to help protect patients from preventable medication errors … Centers for Education and Research on Therapeutics (CERTs) Program focused on drug-drug medication errors … University of Utah Grantee Since: 2009 Type of Grant: Various Related AHRQ Resources Medication Errors

115. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Childbirth: State of the Science PATIENT SAFETY e Issue Brief 6 The Contribution of Diagnostic Errors … e Issue Brief 6 The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During … ‘More than words’ - interpersonal communication, cognitive bias and diagnostic errors. … Reducing diagnostic errors in medicine: what’s the goal?

116. Final Progress Report: Diagnostic Error in Medicine Annual Conference (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/singh2-report.pdf
     January 01, 2025 - errors are especially challenging to detect, track, and correct … (3;4) The relative obscurity of diagnostic errors belies their impact. … Diagnostic errors comprise a substantial and costly fraction of all medical errors. … Understanding diagnostic errors in medicine: a lesson from aviation. … Communication breakdowns and diagnostic errors: a radiology perspective.

117. About the Toolkit Development | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/about.html
     July 01, 2023 - addition to communication failures, patients on labor and delivery (L&D) units are at risk of medication errors … High-reliability systems and a culture of learning from errors (or near misses) are needed to minimize

118. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-1.html
     August 01, 2023 - Research Conclusion References Pediatric clinicians self-report making diagnostic errors … that missed diagnostic opportunities (MDOs) constituted the greatest proportion of care management errors

119. Final Progress Report: A Multiyear Grant To Support the Diagnostic Error in Medicine (DEM) Annual Conference (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/newman-toker-report.pdf
     January 01, 2025 - Diagnostic errors: moving beyond 'no respect' and getting ready for prime time. … Use of health information technology to reduce diagnostic errors. BMJ Qual Saf. 2013. 9. … Diagnostic errors--the next frontier for patient safety. JAMA. 2009;301(10):1060-2. 2. … Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. … Counting deaths due to medical errors. JAMA. 2002;288(19):2404-5. 6. Graber M.

120. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
     January 01, 2024 - errors (42%). … Communication errors (39.6%) and medication errors (39.6%) were frequently reported. … for one in five errors. … , communication errors, and errors involving clinicians and nonclinicians. … errors in which the provider of record is a direct participant; errors of judgment and knowledge; errors