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201. 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

202. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
     March 12, 2008 - the override mechanism and administering prior to pharmacy review increases the risk for medication errors … Numerous medication errors secondary to ADM override have been identified in the literature. … The remaining eight overrides (1.7 percent of total overrides) were a result of medication errors or … found errors in pharmacy, in nursing, and in the ADMs themselves. … Medication errors, 2nd edition. Washington, DC: APhA Publications; 2007. 3. Paparella S.

203. 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

204. 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.

205. Challenges to Real-Time Decision Support in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
     January 01, 2007 - Such errors are more 1 likely to be committed by overconfident physicians. … Commission errors are less common than omission errors.3 The problems associated with medical errors … are associated with proportionately more morbidity than are other types of medical errors. … The importance of cognitive errors in diagnosis and strategies to minimize them. … An objective analysis of process errors in trauma resuscitation.

206. 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

207. 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

208. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
     May 01, 2003 - , but an incomplete review of common latent errors contributing to these events. … Barriers to acceptance of medical errors: the case for a teaching program. … Discussion of medical errors in morbidity and mortality conferences. … A system for analyzing medical errors to improve GME curricula and programs. … Why do errors occur? Ambul Outreach 2000 (Spring):16–20. 21.

209. The Potential of Psychological Safety and Organizational Safety Culture To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-psychological-safety-2.html
     September 01, 2023 - Clinician Psychological Safety in Reporting and Discussing Diagnostic Error Learning From Diagnostic Errors … Improve Diagnostic Safety Specific Barriers and Challenges to Reporting and Learning From Diagnostic Errors … concept is generally used in patient safety to encourage transparent and open discussion of hazards and errors … The goal of reporting and analyzing errors should be to promote insight, create solutions, and enable … firmly embedded in patient safety, but evidence is limited around their role in addressing diagnostic errors

210. 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

211. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
     January 01, 2024 - Predicting and Detecting Drug Name Confusion Errors 3.A. … Automated detection of look-alike/sound-alike medication errors. … Both studies nonetheless found scores of potential errors. … Does Tall Man lettering prevent drug name confusion errors? … How many hospital pharmacy medication dispensing errors go undetected?

212. Final Progress Report: Auditory Perception of Drug Names: Neighborhood Effects (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/lambert3-report.pdf
     January 01, 2024 - One in six medication errors involves name confusion. … attributable to medical errors, but most agree that errors are a threat to patient safety.2,3 Errors … Substitution errors are more interesting, because they correspond to potentially harmful wrong-drug errors … There were 1408 substitution errors overall. … Total number (%) 1783 (14.6%) 1408 (9.66%) 1268 (9.20) 285 % of errors that were substitution errors

213. 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.

214. Final Progress Report: Systems Approach for Improving Region-Wide Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/sirio2-report.pdf
     January 01, 2024 - 1) To understand how well the Reporting Systems associated with nosocomial infections and medical errors … Medication Errors and MedMARx. … These include (1) reporting systems that incorporate standard definitions for errors; (2) reporting … errors through the USP’s MedMARx system. … Total errors reported approached 20,000 and represented over 6.0% of all reported errors in the Medmarx

215. 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.

216. 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.

217. The Timeline to Diagnostic Safety SIDM -Research as a Priority (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
     January 01, 2017 - George Bernard Shaw Measuring Diagnostic Errors 15 Human Factors What factors make dx easier … • ER The petri dish for diagnostic errors • Inpatients One in ten diagnoses is probably wrong. 36,000 … Dx errors are COMMON in patients with anemia, asthma, COPD CRICO - Analysis of 4519 claims related … Slide Number 25 Slide Number 26 Diagnostic errors are a significant but underappreciated challenge … BLUNT end���� SHARP end Safer Dx Framework for Measurement & Reduction Measuring Diagnostic Errors

218. Christiana Care Health System: Safety Mentor Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell_94.pdf
     March 30, 2008 - the Institute of Medicine, as many as 98,000 patients die each year because of preventable medical errors … The Christiana Care Health System is committed to eliminating preventable medical errors. … is going to have greater difficulty identifying system issues that contribute to errors. … that positive process changes have occurred because these errors are being identified. … “Concerning patient safety and medical errors.” Testimony before U.S.

219. Error Producing Conditions in the Intensive Care Unit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - Among the areas where errors occur frequently is the intensive care unit (ICU). … to errors in the ICU. … The first section focused on errors in the ICU in general. … making errors”; and others. … Causes of prescribing errors in hospital inpatients: A prospective study.

220. Final Progress Report: Patient Safety and the Primary Care Testing Process (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/elder-report.pdf
     January 01, 2025 - Key Words: Medical errors; patient safety; primary care 2 3. … , implementation and return of results, accounting for 59% of the total errors. … A preliminary taxonomy of medical errors in family practice. … An international taxonomy for errors in general practice: a pilot study. … A system of analyzing medical errors to improve GME curricula and programs.