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21. Final Progress Report: Utility of Predictive Systems in Diagnostic Errors (UPSIDE) (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/auerbach-report.pdf
    January 01, 2025 - Final Progress Report: Utility of Predictive Systems in Diagnostic Errors (UPSIDE) 1. … , and the harms caused by diagnostic errors. … • Harms due to diagnostic errors: Errors were judged to have contributed to temporary harm, permanent … Similar to errors resulting from procedural complications or certain medication errors, chart reviews … high, with errors being associated with substantial harm.

22. Final Progress Report: Real-time assessment of risk factors for medication errors (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/dresselhaus-report.pdf
    January 01, 2024 - is key to preventing or reducing many such errors. … Nurse ¥ Infusion errors ¥ Self-reported errors ¥ Pharmacist interventions Adverse Drug Events Data … medication errors. … Real-time assessment of risk factors for medication errors. … is key to preventing or reducing many such errors.

23. Final Progress Report: A Memory-Based Approach to Reducing Medication Errors (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/kazi-report.pdf
    January 01, 2024 - studied, medication administration errors (MAEs) remain a persistent problem in healthcare, with errors … Errors in Anticoagulation Therapy through EHR data Results Interview Study PM-based Medication Errors … Errors in Anticoagulation Therapy through EHR data Results Interview Study PM-based Medication Errors … Errors in Anticoagulation Therapy through EHR data Results Interview Study PM-based Medication Errors … Errors in Anticoagulation Therapy through EHR data Results Interview Study PM-based Medication Errors

24. Final Progress Report: Improving Patient Safety by Reducing Medication Errors (pdf file)
    www.ahrq.gov/sites/default/files/2024-03/strom2-report.pdf
    January 01, 2024 - and possibly facilitated errors. … Prescribing errors are the major source of medical errors and largest proportion of medication errors … or perceptions of errors. … In addition to perceived errors and observed errors, we have also determined (see below) that 67% … to errors they prevent.

25. Improving Diagnosis in the Context of Rurality | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-rural-healthcare2.html
    October 01, 2024 - A Call To Action: Diagnostic Excellence In Rural Healthcare References Diagnostic errors … According to the Agency for Healthcare Research and Quality (AHRQ), these errors contribute to approximately … 17 percent of hospital adverse events. 4   The National Academy of Medicine (NAM) defines diagnostic errors … These errors result in delayed, incorrect, or missed diagnoses, often causing irreversible harm and increased … Addressing diagnostic errors in rural healthcare is critical for improving patient outcomes and ensuring

26. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: 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-2/vol1/Advances-West_102.pdf
    March 31, 2008 - levels of harm: (1) prescription drug errors, (2) coordination of care errors (specifically errors … Prescribing errors. … Clinical activity errors included mistimed procedures, examination errors, diagnostic errors, and delays … errors. … errors.

27. Using Home Visits to Understand Medication Errors in Children (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Walsh_74.pdf
    May 28, 2008 - Errors in Children Kathleen E. … , administration errors). … systematically interviewed parents about medical errors, and none addressed errors in ambulatory care … Medication filling and refilling errors. 2. Medication administration errors. 3. … , and administration errors.

28. Methodological Challenges in Describing Medication Dosing Errors in Children (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
    January 01, 2004 - Background Errors of medication use are among the most common types of medical errors and include … errors. … Over half of these errors were dosing or frequency errors, and the physician ordering the medication … committed the majority of these errors. … errors may be undercounted.

29. Final Progress Report: Improving Patient Safety by Examining Pathology Errors (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/raab-report.pdf
    January 01, 2025 - The pulmonary cytology false-negative errors comprised less than 2% of all the false-negative errors … Errors in anatomic pathology. … Cytology errors. Lauren V. … Errors in cancer diagnosis. … Histopathology errors.

30. 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

31. Toolkit for Engaging Patients To Improve Diagnostic Safety  | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/tools/engaging-patients-improve.html
    April 01, 2025 - Toolkit for Engaging Patients To Improve Diagnostic Safety  Diagnostic errors occur in all care … communication breakdowns during the patient-provider encounter are a leading contributor to diagnostic errors … Research suggests that 79 percent of diagnostic errors are related to the patient-clinician encounter … and up to 56 percent of these errors are related to miscommunication during the encounter. … , uninterrupted, and in a way that gives clinicians the information they need can reduce diagnostic errors

32. Final Progress Report: Reducing Harm to Patients from Diagnostic Errors (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/berner-report.pdf
    January 01, 2025 - Final Progress Report: Reducing Harm to Patients from Diagnostic Errors Final Progress Report Reducing … Harm to Patients from Diagnostic Errors Eta S. … A second diagnostic errors conference, led by Dr. … Dual processing and diagnostic errors. … Diagnostic errors in ambulatory care: dimensions and preventive strategies.

33. Final Progress Report: Reducing Diagnostic Errors in Primary Care Pediatrics (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/rinke-report.pdf
    January 01, 2025 - Final Progress Report: Reducing Diagnostic Errors in Primary Care Pediatrics 1. … Key Words: Ambulatory, diagnostic errors, pediatric 3. … data for those errors but not for BP. … Diagnostic errors in primary care pediatrics: Project RedDE. … Diagnostic Errors in Primary Care Pediatrics: Project RedDE.

34. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
    November 29, 2004 - , including both errors of omission and errors of commission. … For some types of errors, such as drug-related errors, denominators that included only those patients … Of those with errors, 1,796 had one error, 1,570 had 2 errors, 191 had 3 errors, and 14 had 4 errors … to glucose and lipid errors. … Overall, patients with glucose errors are significantly more likely to have analogous lipid errors.

35. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
    July 17, 2008 - Introduction The Risk from Medication Errors Medication errors are the most common source of risk … The index has a reported kappa value of κ = 0.62.19 Category B errors are actual errors that were intercepted … CAHs that reported 8,087 medication errors and 143 NFCHs that reported 159,519 errors (Table 2). … Harmful errors (Categories E - I) accounted for approximately 2 percent of reported errors from the … Reporting of Errors by Pharmacy Personnel Of the 156,089 actual errors reported (Categories B - I)

36. Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
    March 21, 2008 - Errors were identified in 84 of the cases (34.1 percent). … Not all errors result in harm to a patient; some errors are discovered before harm takes place. … Errors were identified for 84 of the medication management encounters (34.1 percent); 67 errors (80 … percent) were chart documentation errors. … The chart review identified 66 additional errors, mostly documentation errors; 16 of the errors (19.1

37. Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative (pdf file)
    www.ahrq.gov/downloads/pub/advances/vol2/pace.pdf
    January 01, 2004 - Discussion: Approaches to classifying medical errors vary widely. … errors. … , errors involving patient care outside of the office, and errors in the referral Advances in Patient … Discussion Approaches to classifying medical errors vary widely. … A preliminary taxonomy of medical errors in family practice.

38. Developing a Taxonomy for Coding Ambulatory Medical Errors: 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/Pace.pdf
    January 01, 2004 - Discussion: Approaches to classifying medical errors vary widely. … errors. … , errors involving patient care outside of the office, and errors in the referral Advances in Patient … Discussion Approaches to classifying medical errors vary widely. … A preliminary taxonomy of medical errors in family practice.

39. Why Checklists for Diagnosis Are Not Performing as Expected | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/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

40. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
    January 01, 2004 - Of the medication errors reviewed, errors resulting in permanent harm accounted for 18 percent, near-death … errors accounted for 48 percent, and errors resulting in death accounted for 23 percent of the reports … Analysis of New York Medication Errors 135 Figure 1. … This finding is not unexpected, as 90 percent of the errors involved administration of a drug (errors … The pharmacist or nurse may intercept prescribing errors and the nurse may catch dispensing errors.