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181. The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Phillips.pdf
     January 01, 2004 - These could be administrative or clinical errors. … The most commonly reported health process errors in all three studies were office administration errors … Errors in the first two studies were reported only by physicians, but errors in the third study were … AAFP study, all errors were coded. … that might avert testing process errors.

182. Hospitals and Health Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/index.html
     February 01, 2025 - recommendations, and other resources for hospitals and hospital administrators to improve quality, reduce errors … Toolkits, recommendations, and other resources for long-term care facilities to improve quality, reduce errors

183. A Strategic Approach for Funding Research: The Agency for Healthcare Research and Quality’s Patient Safety Initiative 2000–2004 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keyes.pdf
     January 01, 2004 - Selker, TIPI Systems to Reduce Errors in Emergency Cardiac Care). 3. … • What causes medical errors? • What role does human factors play in medical errors? … the epidemiology of errors; the impact of systems and culture on errors and patient safety, defined … errors. … Research agenda: medical errors and patient safety.

184. From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
     January 01, 2004 - The Error Tool Survey, also completed by team members, assessed the kinds of errors that were actually … The medication errors generally involved one of three issues: incorrect dose, time, or port. … , review of errors, or Patient Safety in Rural Settings 385 analysis of errors.12 Indeed only … , these were usually recognized as errors, identified as such, and attributed to nursing. … Most health care providers said they were comfortable talking about errors.

185. Inpatient-to-Outpatient Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions5.html
     June 01, 2023 - care. 88 This section will review inpatient-to-outpatient handoff-specific contributors to diagnostic errors … and uncertainty and discuss strategies to mitigate diagnostic errors and uncertainty. … Inpatient-to-Outpatient Handoff-Specific Contributors to Diagnostic Errors and Uncertainty Patients … and clinicians' diagnostic reasoning. 92 The most common contributing factors to clinical reasoning errors … Strategies To Mitigate Diagnostic Errors and Uncertainty at Inpatient-to-Outpatient Transitions The

186. Inpatient-to-Outpatient Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html
     June 01, 2023 - care. 88 This section will review inpatient-to-outpatient handoff-specific contributors to diagnostic errors … and uncertainty and discuss strategies to mitigate diagnostic errors and uncertainty. … Inpatient-to-Outpatient Handoff-Specific Contributors to Diagnostic Errors and Uncertainty Patients … and clinicians' diagnostic reasoning. 92 The most common contributing factors to clinical reasoning errors … Strategies To Mitigate Diagnostic Errors and Uncertainty at Inpatient-to-Outpatient Transitions The

187. 3. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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.

188. 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.

189. 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.

190. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
     March 01, 2004 - Detecting and reporting medical errors: why the dilemma? BMJ 2000;320(7237):794–6. 7. … Medication errors. Causes prevention, and risk management. … House passes bill to track medical errors. The Washington Post; Mar 12, 2003. … Taxonomy of medication errors. … Ranked top 10 inpatient products involved in errors that reached the patient, Table 4.

191. A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
     June 11, 2003 - or make errors difficult to detect and intercept. … hospitals can use to anonymously report and track medication errors in a standard format. … Medication errors are immediately reported to the MEDMARX database as well. … AFIP extracts aggregate data on medication errors directly from MEDMARX on a monthly basis. … Truly it is a team effort in reducing the chances of errors.

192. On-line Patient Safety Climate Survey: Tool Development and Lessons Learned (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Connelly.pdf
     January 01, 2003 - The first factor included items on reporting errors and sharing information. … people in this MTF regularly report errors,” and “Most people in this MTF regularly report errors whether … Lucian Leape on the causes and prevention of errors and adverse events in health care. … Follow-up conversation with Lucian Leape on errors and adverse events in health care. … In: Enhancing patient safety and reducing errors.

193. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
     June 30, 2004 - Reported events are only a subset of all medical errors that occur. … Case example: diagnostic testing errors We selected diagnostic testing errors for analysis because … by communication errors, especially to the clinician of record; missing information; procedural errors … Although reported medical errors, like errors in general, typically involve a series of actions gone … , communication errors, and errors involving clinicians and nonclinicians.

194. 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

195. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
     January 01, 2016 - Quality Measures xxVoluntary Reporting Chart Reviews Trigger Tools Automated Measures • 1% of errors … reported • Good for analysis of errors • Not useful as an outcome measure to test interventions … Wrong Patient Errors Leading to Diagnostic Errors: 1) Order tests on wrong-patient 2) Read results of … Wrong Patient Errors Leading to Diagnostic Errors xxVoluntary Reporting Chart Reviews Trigger … Medication Errors in Pediatric Inpatients Charts reviewed of 1120 patients.

196. Improving the Safety and Quality of Medications and Diagnosis | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-schiff.html
     July 01, 2017 - "We can reduce medication errors by including a key piece of information that is currently missing from … Findings from this project shed new light on the magnitude, type, and patterns of diagnostic errors. … Nearly 600 diagnostic errors were reported by physicians surveyed by Dr. … Nearly half (44 percent) of the errors occurred during testing and nearly a third (32 percent) during … It revealed that the large majority (72 percent) of primary care malpractice cases were due to errors

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. Research Agenda | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/maternal-mortality-4.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Research Agenda Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors … Response Cognitive Errors Significant evidence exists to suggest that providers may be affected by … underlying cognitive errors. … Determine impact of various cognitive errors (e.g., implicit bias, anchoring, confirmation, knowledge

199. Research Agenda | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-4.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Research Agenda Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors … Response Cognitive Errors Significant evidence exists to suggest that providers may be affected by … underlying cognitive errors. … Determine impact of various cognitive errors (e.g., implicit bias, anchoring, confirmation, knowledge

200. Improving Patient Safety Systems for Limited English Proficiency Patients
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/hospitalguide/lephospitalguide.pptx
     January 01, 2011 - Culture for Safety of Diverse Patient Populations Adapt Current Systems To Better Identify Medical Errors … Among LEP Patients Improve Reporting of Medical Errors for LEP Patients Routinely Monitor Patient Safety … for LEP Patients Address Root Causes To Prevent Medical Errors Among LEP Patients Improving Patient … LEP and culturally diverse patients Present five key strategies for improving detection of medical errors … Among LEP Patients Adapt systems to better identify medical errors, improve the capacity of patient