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201. Final Progress Report: The Effect of EMR on Medication Safety: A SPUR-Net Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14406-Kuo-draft-1.pdf
     March 01, 2005 - 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).

202. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
     April 04, 2008 - • Insight into causes, cascades, and consequences of errors. … and opportunities for errors, including errors that may occur in transitions between different parts … in rates of errors but may merely represent differences in reporting behavior. … necessarily the errors that occur most frequently. … and discourage blame and punishment for errors that are due to systemic problems.

203. Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Zhang.pdf
     January 01, 2004 - Turley Abstract Human errors in medical device use account for a large portion of medical errors. … from errors, and recover from errors. 9. … [Error] Prevent errors. … Users should be allowed to recover from errors. … Human errors in medical device use account for a large proportion of medical errors.

204. Final Progress Report: Technology To Improve Medication Safety in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14281-Scott-Cawiezell-draft-1.pdf
     September 29, 2007 - 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=

205. Risk-Based Patient Safety Metrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Scanlon_62.pdf
     March 25, 2008 - Finally, errors can guide improvements. … If errors are the source of unsafe health care, then one needs to prevent the errors s . … All errors are recognized by the observer as errors. … In the case of errors and injuries, the previously discussed metrics are attempts to reflect all errors … In using errors and injuries as sources for identifying risk, the rates of errors and injuries are irrelevant

206. 1. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-current-state1.html
     January 01, 2024 - Interview Guide Diagnostic errors have emerged as a major patient safety concern. … Research has shown unacceptable rates of diagnostic errors in acute care, ambulatory care, and emergency … diagnostic error. 2 These estimates are consistent with data from the general public about diagnostic errors … Findings have several implications for future resource investments to reduce harm from diagnostic errors

207. Improving Patient Safety Systems for Limited-English-Proficient (LEP) Patients: A Guide for Hospitals | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps/lep/hospitalguide/lephospitalguide.html
     December 01, 2012 - Improve Reporting of Medical Errors for LEP Patients. … Address Root Causes To Prevent Medical Errors Among LEP Patients. … Ineffective or improper use of medications or serious medication errors. … Improve Reporting of Medical Errors for LEP Patients. … Address Root Causes To Prevent Medical Errors Among LEP Patients.

208. Measures of Cognitive Load | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load4.html
     May 01, 2024 - Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors … tools to study if perception of rising cognitive load is associated with increased risk of diagnostic errors … which may mean that high levels of cognitive load are an important variable associated with diagnostic errors … , despite a large body of literature linking cognitive overload with other types of medical errors. … Assessments could be done by the treating clinician to allow self-identification of errors, along with

209. Final Progress Report: Shared Decision Making in Surgery To Improve Patient Safety and Reduce Liability (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
     January 01, 2024 - All other files were classified as medical errors. … Medical Errors Total N=129 Complaints N=82 Medical Errors N=47 p value Age in years 0.247 Mean … 19%), medication errors (15%), and laboratory errors (11%). … Other errors occurring in 5% or more cases were medical or surgical management errors (9%), wrong treatment … Medical errors leading to complaints included medication errors (n=5), equipment injuries (n=3), diagnosis

210. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-current-state-references.html
     January 01, 2024 - Types and origins of diagnostic errors in primary care settings. … A critical appraisal of AHRQ’’s ““diagnostic errors”“ report. … Finding diagnostic errors in children admitted to the PICU. … Strategies to reduce diagnostic errors: a systematic review. … Reducing diagnostic errors in primary care.

211. Final Progress Report: Ambulatory Pediatric Patient Safety Learning Lab: Pursuing Safe Healthcare at Home (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/walsh-kirkendall-report.pdf
     January 01, 2025 - In previously published case studies of insulin administration errors, most errors were in administration … and treatment delays in children with T1D, we found errors were common. … Medication errors in the homes of children with chronic conditions. … Medication Errors in the Home: A Multisite Study of Children With Cancer. … Using home visits to understand medication errors in children. 2008 32.

212. Resources Related to Diagnostic Safety and Quality | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/index.html
     March 01, 2025 - The PRIDx framework to engage payers in reducing diagnostic errors in health care . … AHRQ Views Blogs With Increased Funding, AHRQ To Explore Scope and Causes of Diagnostic Errors (March … Patient Safety's Next Great Frontier (October 2016) New Coalition Broadens Efforts To Reduce Diagnostic Errors …  (September 2015) New Report Outlines Goals and Recommendations To Reduce Diagnostic Errors  (September

213. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-pediatric-safety-refs.html
     August 01, 2023 - Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics . … Overcoming Diagnostic Errors in Medical Practice. J Pediatr . … The potential for errors in children with special health care needs. … Medication errors in the homes of children with chronic conditions. … Diagnostic Errors and Diagnostic Calibration. JAMA .

214. 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

215. 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.

216. Measure Dx: Making Diagnostic Safety Your Measurement Priority (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/MeasureDx-infographic.pdf
     July 01, 2022 - Measurement Priority Measure Dx Making Diagnostic Safety Your Measurement Priority 1 Why Diagnostic errors … experience a diagnostic error in the outpatient setting every year.a About 250,000 harmful diagnostic errors … The frequency of diagnostic errors in outpatient care: estimations from three large observational studies … Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta- analysis

217. 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.

218. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology-references.html
     April 01, 2025 - Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. … Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care. … Implementation of electronic triggers to identify diagnostic errors in emergency departments. … Use of e-triggers to identify diagnostic errors in the paediatric ED. … Detection and classification of diagnostic discrepancies (errors) in surgical pathology.

219. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-5.html
     June 01, 2020 - Types and origins of diagnostic errors in primary care settings. … Autopsy-detected diagnostic errors over time in the intensive care unit. … Finding diagnostic errors in children admitted to the PICU. … Use of a novel, modified fishbone diagram to analyze diagnostic errors. … OPSI Offers Free Diagnostic Errors Webinar on Sept. 19.

220. Improving the Safety of Diagnosis and Therapy in the Inpatient Setting | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/improving-safety-diagnosis-long-desc.html
     February 01, 2024 - Utility of Predictive Systems in Diagnostic Errors (UPSIDE) study . … Providers' and Patients' Perspectives on Diagnostic Errors in the Acute Care Setting . … Analyzing diagnostic errors in the acute setting: a process-driven approach . … design and development of a diagnostic time-out to address diagnostic errors in acute care . … Analyzing diagnostic errors in the acute setting: a process-driven approach.