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181. The Impact of a Patient Safety Program on Medical Error Reporting (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Woolever.pdf
     January 01, 2001 - Medical facilities have long had systems in place to monitor errors. … Formal teamwork training improved teamwork and reduced emergency department errors. … A look into the nature and causes of human errors in the intensive care unit. … Medical Team Management: using teamwork to prevent medical errors. … Treat systems, not errors, experts say. JAMA 1996;276:1537–8. 23.

182. Implications for Practice Improvement, Research, and Policy | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults3.html
     August 01, 2024 - Recent efforts have called for the study and mitigation of harm from diagnostic errors in older adult … Ongoing efforts to reduce diagnostic errors specifically in older adult populations are highlighted below … Policy Diagnostic errors are a multipronged problem, as discussed earlier. … Developing policies to support the voluntary reporting of diagnostic errors and near-misses.  … These requirements can be broadened to cover diagnostic errors, including formats to report commonly

183. A Model-based Approach to Prioritizing Medical Safety Practices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
     January 01, 2004 - The next largest cause of errors was incorrectly written drug names. … Below that optimal level, errors decrease with the increasing workload; above it, however, errors increase … Errors today and errors tomorrow. New Engl J Med 2003 (348):2570–72. 11. … Variables associated with medication errors in pediatric emergency medicine. … medication errors, 2001.

184. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
     www.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.

185. Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/index.html
     January 01, 2007 - To Improve Diagnostic Safety and Quality Find AHRQ tools to reduce diagnostic errors … on Diagnostic Safety and Quality Learn about AHRQ's research to better understand how diagnostic errors … Diagnostic errors occur in all settings of care; it’s estimated that 795,000 Americans become permanently … AHRQ funds research to better understand how diagnostic errors happen and what can be done to prevent … Tools To Improve Diagnostic Safety AHRQ has several tools to reduce diagnostic errors

186. Final Progress Report: Partnering With Patients To Find Adverse Events (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/weingart2-report.pdf
     January 01, 2024 - Inpatients reported adverse events at a rate of 8.7% and near-miss errors at a rate of 5.7%. … Patients may make valuable partners in identifying medical errors for several reasons. … What types of adverse events and errors to patients report? … Do patient reports of adverse events and errors affect the quality of care? … Medication errors in nursing homes and small hospitals.

187. Making Healthcare Safer Practices: 12. Infusion Pumps (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/infusion-pumps-1.pdf
     March 01, 2020 - of programming errors and equipment failures has not been eliminated. … Key Findings: Outcomes • Four studies reported medication administration errors, procedural errors … Do smart pumps actually reduce medication errors? … , but relatively few were harmful errors. … of programming errors.

188. Patient Safety Research in Medical Group Practices: Measurement and Data Challenges (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Wilson.pdf
     December 01, 2004 - We refer to these instances as errors. … The errors show how the process failed the patient. … and concluded that they could be classified as either process errors or knowledge/skills errors. … detecting errors. … Consequences of medical errors observed by family physicians.

189. 10 Patient Safety Tips for Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/10-tips/index.html
     June 01, 2018 - 10 Patient Safety Tips for Hospitals Medical errors may occur in different health … patient safety information with Patient Safety Organizations (PSOs) to help others avoid preventable errors … Prevent medication errors by offering pharmacists well-lit, quiet, private spaces so they can fill prescriptions

190. News Media and Health Care Providers at the Crossroads of Medical Adverse Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
     June 05, 2008 - • Assisting health care providers in reducing medical errors. … • Developing “best practices” aimed at reducing medical errors. … Errors as an individual-level phenomenon. … Perceived Causes of Medical Errors News media professionals in Indiana believed that medical errors … Medical errors: The scope of the problem. AHRQ Pub. 00-P037.

191. Final Progress Report: Teamwork and Error in Neonatal Intensive Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/thomas2-report.pdf
     January 01, 2024 - Scope: Neonates are vulnerable patients and often the unfortunate victims of medical errors. … Purpose Medical errors and the adverse events they lead to are common and expensive. … Neonates are vulnerable to errors, and errors occur frequently in NICUs. … Improved teamwork could play a role in preventing errors in NICUs. … Primary outcome measures will include errors and teamwork.

192. Final Progress Report: Medication Error Reduction, Technologies and Human Factors (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/carayon-report.pdf
     January 01, 2024 - Medication administration errors decreased, and pump related errors were few. … Nearly half of medication errors are preventable (Leape, 1995). … Smart IV Pump Implementation Impact on Medication Errors D1.1. … Smart IV Pump Implementation Impact on Medication Errors E1.1. … errors reported pre- and post- implementation, respectively.

193. 3. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
     January 01, 2024 - Incidence and Contributing Factors This domain covers the frequency of diagnostic errors and factors … Incidence Quantifying diagnostic errors through incidence rates and other methodologies helps provide … studies have now demonstrated that diagnostic errors are frequent or harmful in different healthcare … Contributing Factors Studies show that diagnostic errors nearly always have multifaceted causes and … Burden The burden of diagnostic errors exists beyond just health outcomes.

194. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - Errors were collected using an established multifaceted surveillance methodology. … Measuring errors and adverse events. … events to study rates of serious medical errors and adverse events. … Detection of Errors and Adverse Events. … Fatigue, sleepiness, and medical errors.

195. Diagnostic Safety Centers of Excellence Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/grants-2022.html
     July 01, 2025 - 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. … , and develop ways hospitals, clinicians, and patients can work together to avoid diagnostic errors and … Project Aims Characterize the diagnostic journey, focusing on successes, errors, and patient/family and

196. Final Progress Report: HIV/HCV Support Team to Improve Medication Safety and Engagement in Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/berry-report.pdf
     January 01, 2024 - (89% reduction) with persisting errors. … Secondary analyses examined incomplete regimen errors and any-type errors on the day of discharge. … reductionA 15 0.98 HCV Rx errors (all) 49 (29% of 170) 50% reductionB 24 0.88 HCV Rx errors (incomplete … HIV Medication Errors For the co-primary outcome of antiretroviral-related medication errors, our study … medication errors, which we categorized as incomplete regimen errors, dosing errors, and use of combinations

197. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
     January 01, 2024 - , Medical errors, Quality of health care A. … There are many types of errors. … Research has traditionally focused on errors of commission, things we did but shouldn’t have. … Various methods have been utilized to decrease errors of both commission and omission in healthcare … Organizational changes to IUMG-PC to decrease errors of commission and omission.

198. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error (pdf file)
     www.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.

199. Diagnostic error in mental health: a review (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-mental-health-bmjqs.pdf
     April 15, 2024 - ABSTRACT Diagnostic errors are associated with patient harm and suboptimal outcomes. … Interventions to reduce diagnostic errors in mental health need further development. … Identifying psychiatric diagnostic errors with the safer DX instrument. … Toward understanding errors in inpatient psychiatry: a qualitative inquiry. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

200. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
     September 28, 2016 - Series Foundational Reports 1999 2001 To Err is Human: Building a Safer Health System • Medical errors … action to be completed as intended or the use of a wrong plan to achieve an aim • The majority of errors … • Errors cost $17 billion – $29 billion per year in hospitals in the US However, more recent data … . • Develop a knowledge base for learning about errors' causes and effective error prevention … • Diagnostic errors are the leading type of paid medical malpractice claims • Diagnostic errors can