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141. www.ahrq.gov/research/findings/factsheets/errors-safety/workfact/
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142. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions1.html
     June 01, 2023 - responsibility and handoffs are widely recognized as high-risk times when the potential for cognitive errors … 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

143. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions1.html
     June 01, 2023 - responsibility and handoffs are widely recognized as high-risk times when the potential for cognitive errors … 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

144. 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.

145. Final Progress Report: : State of the Science on Safe Medication Administration (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/barnsteiner-report.pdf
     January 01, 2024 - • What are best practices for identifying errors? … • Can a taxonomy of errors improve error reporting? … How does team participation affect medication errors? … ) and adversely (fatigue can increase errors)? … • Do magnet hospitals have lower rates of medication errors?

146. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 - The most common types of errors were inappropriate abbreviations, followed by dosing errors. … The most frequent cause of errors was illegibility. … of 6.3 serious medication errors per 1000 patient-days. … a high rate of nursing transcription errors (20%). … Overall, we found a total of 219 IV medication errors.

147. Health Literacy–Informed Intervention Reduces Pediatric Caregiver Liquid Medication Dosing Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/911.html
     April 01, 2024 - Health Literacy–Informed Intervention Reduces Pediatric Caregiver Liquid Medication Dosing Errors … Headlines: Health Literacy–Informed Intervention Reduces Pediatric Caregiver Liquid Medication Dosing Errors … Health Literacy–Informed Intervention Reduces Pediatric Caregiver Liquid Medication Dosing Errors Providing … literacy–informed tools and information to caregivers significantly reduced liquid medication dosing errors … They found that dosing errors dropped by half, from 54.2 percent in the standard counseling group to

148. Final Progress Report: Using Barcode Technology to Improve Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14053-Gandhi-draft-1.pdf
     April 16, 2007 - that are potential ADEs Entire pharmacy Pre & post Review of medication dispensing errors by … that are potential ADEs and ii) ADEs due to medication transcribing and administering errors 2 ➢ … Measures included target dispensing errors, defined as dispensing errors that barcode technology was … Gandhi 4.16.07 6 pharmacy with undetected errors. … How many hospital pharmacy medication dispensing errors go undetected?

149. Development of a Multipurpose Dataset to Evaluate Potential Medication Errors in Ambulatory Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Chan.pdf
     July 01, 2004 - Development of a Multipurpose Dataset to Evaluate Potential Medication Errors in Ambulatory Settings … 225 Development of a Multipurpose Dataset to Evaluate Potential Medication Errors in Ambulatory … Medical errors are now clearly recognized as a serious and common problem in the delivery of health … Developing a Dataset to Evaluate Drug Errors 229 percent in IPAs. … Developing a Dataset to Evaluate Drug Errors 235 Table 4.

150. Study Section Research Foci | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/process/study-section/resfoci.html
     October 01, 2024 - Healthcare Safety and Quality Improvement Research (HSQR) Identify Risks/Hazards that Lead to Medical Errors … and Find Ways to Prevent Medical Errors – Improve Patient Safety Research on the scope and impact of … medical errors on cost, quality, efficiency, and effectiveness of care / Impacts of Medical Errors on … Quality Improvement Research Dissemination/Translation Research Findings and Methods to Reduce Medical Errors

151. Guide for Developing a Community-Based Patient Safety Advisory Council | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/advisorycouncil/adcouncilref.html
     April 01, 2018 - Institute of Medicine, Preventing Medication Errors , Quality Chasm Series. … Medication Errors . 2nd edition. Washington, DC: American Pharmacists Association; 2007. … Partnering with Patients to Reduce Medical Errors .Chicago: American Hospital Association Press; 2004 … Preventing medical errors: Communicating a role for Medicare beneficiaries.

152. The PRIDx framework to engage payers in reducing diagnostic errors in healthcare (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/pridx-framework.pdf
     July 05, 2023 - The PRIDx framework to engage payers in reducing diagnostic errors in healthcare Mini Review Kisha … Blackall and Hardeep Singh The PRIDx framework to engage payers in reducing diagnostic errors in healthcare … Despite growing interest in the measurement and prevention of diagnostic errors, direct engagement of … Advancing the science ofmeasurement of diagnostic errors in healthcare: the Safer Dx framework. … Diagnostic error inmedicine: analysis of 583 physician-reported errors.

153. Final Progress Report: Improving Transplant Med Safety through a Pharmacist-Led, mHealth-Based Program (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/taber-report.pdf
     January 01, 2024 - Participants receiving the intervention experienced a significant reduction in medication errors (61% … We also have found that recipients who develop clinically significant med errors are at considerably … additions, dose errors, incorrect drug, incomplete dosage instructions, prescribing errors, and any … arm (mean 9.0±5.9), leading to a 56% reduction in medication errors in the treatment arm. … Common administrative errors included omissions, additions, and prescribing errors.

154. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … : State of the Science Next Page Table of Contents The Contribution of Diagnostic Errors … The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After

155. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
     February 01, 2025 - Project Aims: Develop a multidisciplinary diagnostic excellence center to address diagnostic errors. … Propose, prioritize, and codesign patient-centered solutions to mitigate diagnostic errors. … , and develop ways hospitals, clinicians, and patients can work together to avoid diagnostic errors and … Diagnostic errors in hospitalized adults who died or were transferred to intensive care. … Project Aims: Characterize the diagnostic journey, focusing on successes, errors, and patient/family

156. ED-to-Hospital Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions2.html
     June 01, 2023 - ED-Specific Contributors to Diagnostic Challenges and to Diagnostic Errors and Uncertainty EDs are … in the ED are generally considered multifactorial. 19 In addition to being common, diagnostic errors … Second, and relatedly, early diagnostic errors can propagate other types of medical errors such as admission … . 12 , 15 ED-to-Ward Handoff-Specific Contributors to Diagnostic Errors and Uncertainty Because of … In conclusion, the ED-to-hospital transition is a high-risk time for diagnostic errors.

157. Advances in Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/advances/index.html
     October 01, 2014 - Implementation describes what federally funded programs have accomplished in understanding medical errors … , Joel Bartfield An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors … Moores Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (   PDF File … Turley Ambulatory and Rural Learning from Errors in Ambulatory Pediatrics (   PDF File , 186 KB) … Wasserman, Lynne Uhring Identification, Classification, and Frequency of Medical Errors in Outpatient

158. The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care (pdf file)
     www.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

159. Final Progress Report: Blood Product Transfusion & Safe Practices (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/herwaldt-report.pdf
     January 01, 2024 - barcode technology, and a new online data-capture-response tool to prevent patient identification errors … Errors and incident reports occurring before and after implementation were analyzed. … Safe practices implementation; Wireless mobile devices; Barcode technology; Patient identification errors … Identification Errors 4/21/04 – 2/07/05 (Pilot Period) Prevented Errors Count Step/ Occurred Step … Prevented errors, a mismatch between the barcoded labels, represented a small proportion of the errors

160. Diagnostic Safety Research (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/DiagnosticSafety-flier.pdf
     November 01, 2024 - Diagnostic errors are common, consequential, and costly and contribute to avoidable suffering and preventable … ■ Each year, 795,000 Americans die or are permanently disabled due to misdiagnosis.1 ■ Diagnostic errors … to progress to a less treatable stage, worsen prognosis, and decrease survival.11-14 Diagnostic errors … and development of a taxonomy for classifying errors … Diagnostic error in medicine: analysis of 583 physician-reported errors.