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241. Special Considerations for Measurement of Diagnostic Safety (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2b.html
     June 01, 2020 - frequency or scope of a problem, but they can help raise awareness of the impact and harm of diagnostic errors … rich detail that, at least in some cases, may offer insight into ways to prevent or mitigate future errors … However, no standardized mechanisms exist to report diagnostic errors. … Despite widespread efforts to enable providers to report errors, 17 , 52 clinicians find reporting tools … onerous and are often unaware of errors they make. 53 It has also become clear that a local champion

242. Developing Innovative Simulation-Based Training to Improve Patient Safety in Radiation Oncology | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-mazur.html
     March 01, 2023 - Radiation therapists are the last line of defense to catch any errors during the treatment planning stage … 600,000 patients who receive radiation therapy annually might be adversely impacted by operational errors … While radiation therapy has relatively low error and injury rates, studies show that most errors occurring … Mazur, “Approximately 40 percent of the errors reported to a national event registry were discovered … Because of the key role radiation therapists play in the detection of errors and in the delivery of the

243. Speaking Plainly: Communicating the Patient’s Role in Health Care Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Miranda.pdf
     July 01, 2004 - Others specified particular actions that patients could take to avoid errors, such as maintaining a … refers to “medical errors.” … Agency for Healthcare Research and Quality: 20 tips to help prevent medical errors. … Preventing medical errors: communicating a role for Medicare beneficiaries. … Prescription errors tied to lack of advice: pharmacists skirting law, Mass. study finds.

244. On World Patient Safety Day, AHRQ Highlights the Urgent Need to Address Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/world-patient-safety-day-2024.html
     September 01, 2024 - Alliance webinar, where experts will share recently developed tools and strategies for reducing diagnostic errors … The need to reduce diagnostic errors is urgent. … These errors disproportionately affect the most vulnerable in our country. … Improve Diagnostic Safety —provide clinical teams and patients with resources to recognize risks, avoid errors … in diagnostic safety to accessing patient experiences as a strategy for understanding the origin of errors

245. New AHRQ SOPS™ Health Information Technology Patient Safety Supplemental Items for Hospitals - Optimizing (Gandhi) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/healthitwebinar/sops-hit-webcast3-gandhi.pdf
     January 01, 2018 - to Improve Safety Tejal Gandhi Handwriting 16 Ways IT Can Improve Safety • Prevent errors … and providing feedback about adverse events Bates, Gawande 2003 Main Strategies for Preventing Errors … decision support Bates, Gawande 2003 Optimize the Use of HIT • We know that some technologies reduce errors … • Overdependence on technology • Shift in power • Never-ending technology demands • Emotions • New errors … Use of HIT to Improve Safety Handwriting Ways IT Can Improve Safety Main Strategies for Preventing Errors

246. The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Karsh.pdf
     April 08, 2004 - , the impact of errors on patient and care systems, and methods to control errors. … , how to design systems with proper defenses against errors, and communication skills. … • Understanding that some latent errors and systemic problems are exacerbated by poor design. … The authors also note that even though people argue that systems problems contribute to medical errors … than systems errors.

247. Final Progress Report: The Value of Hospital-Related Patient-Safety Interventions to Key Stakeholders (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/nuckols-report.pdf
     January 01, 2024 - Process subdomains include appropriateness of care and medical errors. … Two investigators extracted data on pADEs, medication errors, and factors potentially associated with … Results: Sixteen studies addressing medication errors met eligibility and pooling criteria; six also … Higher baseline rates of medication errors predicted greater reductions (p<0.001). … Decreases in medication errors are similar and robust to variations in several important aspects of

248. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-3.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 … Although many Americans describe having heard about “medical errors” in the media, 15 only about half … In hospital settings, this shift in terminology from mistakes/errors to feeling safe roughly doubled … Framing experiences in terms of “mistakes” is more approachable than framing as “diagnostic errors,”

249. Conclusions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-5.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 … Whether or not clinicians or healthcare experts would define diagnostic issues as “errors,” the events … We have the methods to learn more about the impact of diagnostic errors on patients and families.

250. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses6.html
     August 01, 2022 - Diagnostic errors. Acad Emerg Med. 2002;9(7):740-750. doi: 10.1197/aemj.9.7.740 . … Diagnostic Errors in the Emergency Department: A Systematic Review. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Changes in medical errors after implementation of a handoff program. … The importance of cognitive errors in diagnosis and strategies to minimize them.

251. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-rev-0724update.pdf
     July 01, 2024 - medications at Brigham and Women’s Hospital resulted in fewer adverse drug events from dispensing errors … to improve patient safety by reducing harm and identification errors among patients … ■ Reduce patient harms and errors within hospital settings (e.g., falls, adverse drug interactions, … Compared with paper order entry, CPOE was associated with half as many pADEs and medication errors. … Medication administration errors decreased, and few pump-related errors were made.

252. Federal Interagency Workgroup on Improving Diagnostic Safety and Quality in Healthcare | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/workgroup/index.html
     July 01, 2025 - These reports bring attention to the specific problem of diagnostic errors and their effect on the quality … Goal 8 is to provide dedicated funding for research on the diagnostic process and diagnostic errors. … Federal agencies to develop a coordinated research agenda on the diagnostic process and diagnostic errors

253. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-1.html
     September 01, 2020 - instance, checklists have been successful in preventing hospital-acquired infections 1 and preventing errors … surgical process. 2 The use of checklists has also been recommended as a tool to reduce diagnostic errors … . 3 Diagnostic errors are frequent and often have severe consequences 4 but have received little attention

254. Improving Diagnosis in Emergency and Acute Care: A Learning Laboratory (IDEA-LL) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/idea-ll-long-desc.html
     August 01, 2025 - HS26622 Project Period:  09/30/18-07/31/24 Description:  This learning lab sought to reduce diagnostic errors … Identifying diagnostic errors in the emergency department using trigger-based strategies. … Common medical errors in pediatric emergency medicine . … Iterative Refinement of Electronic Triggers To Improve the Identification of Diagnostic Errors (oral … Identification of Diagnostic Errors in the Emergency Department   Using   Data-Driven Strategies. 

255. Guide Promotional Postcard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/pfeprimarycare-infographic.pdf
     April 01, 2018 - Annually, 1 in 20 outpatients experiences a diagnostic error 55% of patients said diagnostic errors … 9 ED admissions are related to an adverse drug event An estimated 160 million medication errors … Reduce errors and improve efficiency by setting the visit agenda together with Be Prepared To Be

256. Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/diagnostic-safety-transitions-care.pdf
     June 01, 2023 - In addition to cognitive errors of omission and commission, communication errors may follow similar … Second, and relatedly, early diagnostic errors can propagate other types of medical errors such as admission … Diagnostic errors in medicine: a case of neglect. … The importance of cognitive errors in diagnosis and strategies to minimize them. … Cognitive errors detected in anaesthesiology: a literature review and pilot study.

257. Final Progress Report: Oral Chemotherapy Safety in Ambulatory Oncology: A Proactive Risk Assessment (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/weingart-report.pdf
     January 01, 2024 - and the quality of information about oral chemotherapy errors from various sources. … We proposed to collect data about oral chemotherapy-related medication errors by using literature and … and the quality of information about oral chemotherapy errors from various sources) 5.1.1 Incident … Underreporting is common, because clinicians may be reluctant to report their own errors. … Medication errors involving oral chemotherapy. Unpublished manuscript.

258. Appendix A | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-apa.html
     April 01, 2018 - Analysis (RCA) '10 Patient Safety Tips for Hospitals' '20 Tips to Help Prevent Medical Errors … in Children' '20 Tips to Help Prevent Medical Errors: Patient Fact Sheet' '30 Safe Practices … Ventilator-Associated Pneumonia' 'Reducing Discrepancies in Medication Orders' 'Reducing Medical Errors … Transforming Hospitals: Designing for Safety and Quality' 'Ways You Can Help Your Family Prevent Medical Errors

259. Breakout Session: Use of Data and Measurement in Improving Diagnostic Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/brady-summit2016-breakout.pdf
     September 28, 2016 - Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses … ► Health Care professional societies should identify opportunities to reduce diagnostic errors in … and medical liability system that facilitates improved diagnosis through learning from diagnostic errors … environment that facilitates the timely identification, disclosure, and learning from diagnostic errors … errors ► Monitor progress in reducing diagnostic errors Measurement Study Example Hospital Admission

260. Final Progress Report: Proactive Risk Reduction in Medication Prescribing in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
     January 01, 2024 - risk assessment to characterize systemic and behavioral elements that increase the risk of serious errors … Scope: There are currently no demonstrably effective solutions to the problem of errors in prescribing … Our previous study identified seven major proximal errors in the medication handling process that cause … for interventions and assess the extent to which these interventions could lower the rate of these errors … Because the errors associated with ADEs in this setting usually occur 3 during prescribing and