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221. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
     January 01, 2024 - The global burden of diagnostic errors in primary care. … Diagnostic errors in paediatric cardiac intensive care. … Finding diagnostic errors in children admitted to the PICU. … Checklists to reduce diagnostic errors. … Reducing diagnostic errors in primary care.

222. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science-brief1.pdf
     April 02, 2020 - Types and origins of diagnostic errors in primary care settings. … Measuring errors and adverse events in health care. … Finding diagnostic errors in children admitted to the PICU. … The global burden of diagnostic errors in primary care. … Malpractice claims related to diagnostic errors in the hospital.

223. Operational Measurement of Diagnostic Safety: State of the Science (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
     April 02, 2020 - Types and origins of diagnostic errors in primary care settings. … Measuring errors and adverse events in health care. … Finding diagnostic errors in children admitted to the PICU. … The global burden of diagnostic errors in primary care. … Malpractice claims related to diagnostic errors in the hospital.

224. Making Healthcare Safer III | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html
     August 01, 2024 - management, healthcare-associated infections, nursing-sensitive practices, procedural events, and diagnostic errors … and disinfection interventions to prevent HAIs, and several practices designed to prevent medication errors … Chapters Diagnostic Errors (PDF, 2.6 MB) Failure To Rescue (PDF, 1.8 MB) Sepsis Recognition (PDF, … Events in Older Adults (PDF, 415.7 KB) Harms Due to Opioids (PDF, 2.1 MB) Patient Identification Errors

225. 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

226. Imbedding Research in Practice to Improve Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Raebel_53.pdf
     May 07, 2008 - Results: All interventions reduced errors (range, 13 to 45 percent), with more than 4,000 errors avoided … Detection of potential errors triggered alerts. … Examining systems issues that contribute to near-misses or errors. … Medication errors were reduced in all projects. … Medication errors drop with Kaiser alert system. Rocky Mountain News; May 27, 2005. 4.

227. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
     January 01, 2024 - The proposed Aims were: Aim 1: To analyze the frequency and determinants of errors and adverse events … Among adverse events, medication errors are of particular concern because they are common, costly, and … Despite the frequency of ambulatory patient safety errors and adverse events, most efforts to study … The ASPIRE reach program sought to address this gap by studying ambulatory patient safety errors for … Third, some important patient safety errors are not amenable to EHR-based quality measurement.

228. Appendix E | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
     April 01, 2018 - 1 406  -- Prostheses and Implants 0 451  -- Restraints 6 407 Diagnostic Errors … Critical Lab Results 0 413 Fatigue and Sleep Deprivation 13 411 Identification Errors … /Preventable Adverse Drug Events 96 420  ---- Administration Errors 14 419  ---- … Dispensing Errors 11 448  ---- Monitoring Errors and Failures 23 417  ---- Ordering … /Prescribing Errors 6 418  ---- Transcription Errors 5 415  -- Side Effects/Adverse

229. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - Discussion: The models provide contextual maps of the errors and behaviors that lead to medication … However, pharmacy dispensing errors—internal or external—that enter the facility are captured in the … per medication order, and errors per oral medication dose. … errors in a district general hospital. … Errors today and errors tomorrow. N Engl J Med 2003;348:2570–2. 24. Blegen MA, Vaughn T.

230. National Academy of Medicine (NAM) Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/national-academy-medicine.html
     February 01, 2018 - AHRQ: Improving Diagnosis in Health Care ,  published in 2015, this report investigates diagnostic errors … Preventing Medication Errors: Quality Chasm Series  Released: July 20, 2006 According to one estimate … Preventing Medication Errors puts forward a national agenda for reducing medication errors based on estimates … of the incidence and cost of such errors and evidence on the efficacy of various prevention strategies … by which government, health care providers, industry, and consumers can reduce preventable medical errors

231. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-1.html
     June 01, 2023 - Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … Patient Experience as a Source for Understanding the Origins, Impact, and Remediation of Diagnostic Errors … broad language, rather than trying to give patients and families more precise definitions of “medical errors … and family conceptions of adverse events do not always conform to clinical definitions of diagnostic errors

232. Final Progress Report: Transitional Care Medication Safety and Reducing Medical Liability: Closing the Chasm (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/corbett-report.pdf
     January 01, 2024 - Scope: The magnitude of medication errors in the United States and the associated human and economic … Key Words: transitional care; medication safety; medication discrepancy; medication errors; adverse … Health systems expend considerable resources reducing medication errors in the hospital setting. … A steep increase in domestic fatal medication errors with use of alcohol and/or street drugs. … Preventing medication errors: Quality Chasm Series. Washington, DC: National Academy of Sciences.

233. Final Progress Report: Creating Learning Cultures Around Mistakes for Residents (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/hoff-report.pdf
     January 01, 2024 - In the surgical culture, appropriate learning best practices around errors and near misses committed … The errors observed varied in terms of source, seriousness, and focus. … Errors * (n=24) MICU Errors (n=27) Individual practices: Habit of inquiry 0 (0/9) 33 (2/6) Self-reflection … Regardless of setting, most errors occurred when the resident was alone. … Learning to avoid learning: The paradoxes of residency training around medical errors.

234. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
     September 01, 2012 - Patient Safety Terminology Medical errors*: Medical errors happen when something that was planned as … Most errors result from problems created by today’s complex health care system, but errors also happen … If anything, errors related to LEP are bundled as being caused by “communication errors,” which does … We identified three common causes of errors (or potential errors) for LEP and culturally diverse patients … Address Root Causes To Prevent Medical Errors Among LEP Patients Background Medical errors among LEP

235. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
     January 01, 2002 - Stress was measured using a 4-item scale, past errors were self reported, and the likelihood of future … errors was self-assessed using the OSPRE (Occupational Stress and PReventable Error) measure. … Regression analyses assessed predictors of stress, past errors, and future errors. … addressed errors committed in the management of common chronic medical conditions. … future errors.

236. Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
     January 01, 2024 - Yet errors are frequently not disclosed to patients. … easily within a blame-free framework for discussing errors. … Disclosing errors to patients: Perspectives of registered nurses. … Health plan members' views about disclosure of medical errors. … Views of practicing physicians and the public on medical errors.

237. Final Progress Report: Conference on Medical Error Communication and Dispute Resolution (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/liebman-hyman-report.pdf
     January 01, 2024 - diverse group of individuals from various disciplines to share information about disclosure of medical errors … medical malpractice claims; and 3) the potential benefits to patient safety from disclosing a medical errors … error, and ways to help physicians and other healthcare providers handle their emotional reactions to errors … , MD, and Eran Bellin, MD, Montefiore Medical Center’s Computerized System for residents to Report Errors … shaping an agenda for overcoming institutional barriers to change regarding disclosure of medical errors

238. Producing Accurate Clinical Quality Reports for Population Health: A Delivery System-Oriented Approach to Report Validation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/ehr-reports.pdf
     March 01, 2016 - They found no errors in the report logic. … For validation purposes it is useful to categorize clinical quality report errors into “inclusion errors … Other inclusion errors can be caused by workflow issues, which are errors caused by failure to note … Exclusion Errors The fact that with exclusion errors the patient is not in the report means that the … All reports contain errors, and 2.

239. Improving Healthcare Safety by Enhancing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-medication-safety.pdf
     April 30, 2025 - characteristics similar to harmful errors. … to errors they prevent. … An important unanticipated benefit was identification of medication errors. … ) while creating other types of MEs (e.g., prescribing errors due to missing information or errors in … Medication administration errors decreased and pump-related errors were few.

240. Final Progress Report: Building Consensus Among States on Patient Safety Reporting (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/golden-west-report.pdf
     January 01, 2024 - occur and the circumstances surrounding those errors … occur and the circumstances surrounding those errors … occur and the circumstances surrounding those errors … Preliminary Research Agenda: Medical Errors and Patient Safety. … National Summit on Medical Errors and Patient Safety Research. October 2000.