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121. 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.

122. Georgia Hospitals Use AHRQ Blood Thinner DVD to Help Reduce Errors, Improve Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0903.html
     October 01, 2014 - Georgia Hospitals Use AHRQ Blood Thinner DVD to Help Reduce Errors, Improve Safety Search All Impact … Association (GHA) are using a video developed as a result of an AHRQ-sponsored project to help combat medical errors … The 55-minute video, Discussing Unanticipated Outcomes and Disclosing Medical Errors, dramatizes right … undertook research to demonstrate that "sincerity pays" and that malpractice claims are less likely when errors … Partnership for Health and Accountability (PHA) Topic(s): Patient Safety, Medical Errors

123. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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.

124. References | Agency for Healthcare Research and Quality
     www.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.

125. Final Progress Report: The Effect of EMR on Medication Safety: A SPUR-Net Study (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/kuo-report.pdf
     January 01, 2024 - other types of MEs (e.g., prescribing errors due to missing information or errors in spelling). … , including errors in ordering medications (13%) and errors in implementing medication orders (6%).1 … reducing such errors. … monitoring errors. … other types of MEs (e.g., prescribing errors due to missing information or errors in spelling).

126. Final Progress Report: Technology To Improve Medication Safety in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/scott-cawiezell-report.pdf
     January 01, 2024 - Scope Earlier research suggests that medication errors, excluding wrong-time errors, average 10% or … , including wrong-time errors. … Although the ICC was lower when considering medication errors without wrong-time medication errors ( … between the rate of interruptions and medication errors when wrong-time medication errors were included … when considering the variable that only included medication errors excluding wrong-time errors (p=

127. Final Progress Report: Risk Models To Improve Long-Term Care Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
     January 01, 2024 - errors (38/1000 doses). … Transcription errors are an important contributor to medication errors,14 but 2 relatively few studies … these transcription errors. … Research on drug-use-system errors. … Calculation and expression of rate errors were found in 17.5% of errors; 13.4%of errors involved incorrect

128. Impoving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/improving_diagnosis_flyer.pdf
     April 01, 2019 - ■ Diagnostic errors affect more than 12 million Americans each year and may seriously harm approximately … ■ Fifty-five percent of patients said diagnostic errors were a chief concern in outpatient visits … AHRQ is also funding research to better understand how diagnostic errors happen, what can be done to … It outlines three key areas of interest: ■ Quantifying the incidence of diagnostic errors. … ■ Understanding what contributes to these errors.

129. Impoving Diagnosis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/Improving_diagnosis_flyer.pdf
     April 01, 2019 - ■ Diagnostic errors affect more than 12 million Americans each year and may seriously harm approximately … ■ Fifty-five percent of patients said diagnostic errors were a chief concern in outpatient visits … AHRQ is also funding research to better understand how diagnostic errors happen, what can be done to … It outlines three key areas of interest: ■ Quantifying the incidence of diagnostic errors. … ■ Understanding what contributes to these errors.

130. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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

131. Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/savage-report.pdf
     January 01, 2024 - Final Progress Report: Developing Definitions, Measurement Strategies, and Links to Medication Errors … Workarounds: Developing Definitions, Measurement Strategies, and Links to Medication Errors Principal … about workarounds and the manner in which workarounds lead to potential patient risk in medication errors … Key Words: Workarounds, Medication Errors, Intensive Care Units, Nursing, Pharmacy 2 Workarounds … Areas of emphasis have included medication prescribing, dispensing, and administration errors.

132. 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

133. AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0802.html
     October 01, 2014 - AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments … June 2008 AHRQ-sponsored research on how clinical pharmacy services can reduce medication-related errors … ASHP aims to prevent medication errors, help people make the best use of medicines, and assist pharmacists

134. Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1.html
     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

135. Final Progress Report: Improve Safety, Quality, and Efficiency in Radiotherapy with Automated HIT System (pdf file)
     www.ahrq.gov/sites/default/files/2024-04/yang-report.pdf
     January 01, 2024 - total errors. … , patient setup errors, and treatment plan errors [53, 60]. … However, detecting errors based on manually defined rules is limited. … , for example, prescription errors. … 40% errors, and potentially prevent the most severe errors in real time.

136. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
     www.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 … as improving diagnosis in pediatric care, how to best learn from patient experiences, how diagnostic errors … They underscore the imperative to mitigate diagnostic errors and harm.

137. Final Progress Report: Patient Safety: Physician Assistant Responsibilities and Opportunities (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/crane-report.pdf
     January 01, 2024 - Reducing medical errors 3. Promoting evidence-based care 4. … : both active errors and latent errors • Safety targets: medication prescribing, patient identification … PAs also agreed that making errors in medicine is inevitable. … share information about errors and their causes. … PAs make errors.

138. 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.

139. www.ahrq.gov/research/findings/factsheets/errors-safety/aderia/
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140. www.ahrq.gov/research/findings/factsheets/errors-safety/simulproj15/
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