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261. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - The majority of errors that occur are considered “near misses”—errors that could have caused harm to … Unfortunately, a small portion of errors do result in an “adverse event”—an injury caused by medical … Events relating to medication errors Medication related errors are one of the most common types of … While not all medication errors result in harm, those that do can be costly. … These types of simulation training can be quite helpful in minimizing transition errors.

262. Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
     April 01, 2025 - ascribed to error or substandard care, called preventable adverse events, was created to capture errors … As the field evolved to consider diagnostic errors as a subset of medical error, the term diagnostic … adverse event 16 was introduced and defined as diagnostic errors that cause harm. … Safety-I often defines factors that contribute to adverse events as failures or errors, even if it uses … One consequence of defining failure or problems as “errors” is a strong tendency by those unfamiliar

263. 170-Cusp-Science-Safety-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
     October 01, 2024 - This module reviews the science of safety to elucidate system factors that lead to errors and strategies … And as humans, we make errors and can fail. Our healthcare system isn’t perfect by any means. … Communication errors are common causes of healthcare errors. … Errors need to be caught before they reach the patient. … Slide 18 Swiss Cheese Model: How Errors Happen SAY: But sometimes defenses fail, and errors line

264. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
     June 01, 2023 - ICU-Specific Contributors to Diagnostic Errors and Uncertainty Due to the high complexity and acuity … information, and both cognitive failures and system-based failures, all of which can lead to diagnostic errors … ICU-to-Ward Handoff-Specific Contributors to Diagnostic Errors and Uncertainty When transitioning from … patient transitioning from the ICU to a ward. 70 , 71 Further research should examine how diagnostic errors … transitions of care. 30 In conclusion, the ICU-to-ward transition is a high-risk time for diagnostic errors

265. Final Progress Report: Improving Safety After Hospitalization in Older Persons on High-Risk Medications (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gurwitz2-report.pdf
     January 01, 2024 - We estimated an incidence rate of medication errors in the comparison group of 0.95. … We also calculated the distribution of levels of severity and source of errors. … Adverse drug events resulting from patient errors in older adults. … Observation method of detecting medication errors. … Medication errors in the homes of children with chronic conditions.

266. Did You Know, Safety Infographic (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/03-diagnostic-safety-infographic.pdf
     August 01, 2021 - attend a primary care appointment this year will experience a diagnostic error.2 79% of diagnostic errors … are related to the patient-clinician encounter.3 up to 56% of these errors are related to miscommunication … Types and origins of diagnostic errors in primary care settings.

267. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
     April 03, 2008 - Anderson Cancer Center to 1 facilitate a proactive approach to preventing errors. … • Providing definitions and examples of actual and potential errors. … One hospital’s journey toward reducing medication errors. … Perceived barriers in reporting medication administration errors. … Reduction of adverse drug events and medication errors in a community hospital setting.

268. Understand the Science of Safety for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
     July 01, 2023 - Slide 3: Health Care Defects Say: Examples of the effect of defects and errors in the U.S. health … In 1999, 44,000 to 99,000 people die from medical errors in hospitals each year. … Slide 4: How Can These Errors Happen? … Providers, executives, and managers need to understand why errors occur. … Errors occur because medicine is still treated as an art, not a science.

269. Discussion of Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/findings.html
     March 01, 2017 - within this domain may include errors in referral and errors in communicating test results. … . 39 , 70 , 97–101 Errors occur at the prescribing, filling, and administration stages of medication … Prescribing errors included prescribing the wrong medication, prescribing medications with drug-drug … interactions, and making errors related to transcription of written prescription orders. … Efforts to reduce medication errors in the ambulatory care setting, including primary care, have focused

270. Post-fielding Surveillance of a Guideline-based Decision Support System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
     January 01, 2004 - , should undergo similar predeployment testing to prevent introduction of new errors. … Analysis of clinician-user feedback facilitated rapid detection and correction of such errors. … Introduction ALL technology introduces new errors, even when its sole purpose is to prevent errors … There were no additional programming, logic, or treatment errors identified by study providers. … Reducing the frequency of errors in medicine using information technology.

271. Making a Case for Organizational Change in Patient Safety Initiatives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Ramanujam.pdf
     January 01, 2003 - These complex processes, themselves vulnerable to errors, are overlaid on a health care culture that … Implementing this strategy will require several changes: redesigning work processes to make errors more … context where practitioners feel psychologically safe about discussing their errors and seeking help … Employees at the point of care must acquire the capabilities to analyze errors locally and implement … same errors continued to occur, so they stopped reporting.

272. New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Schiff (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new_sops_diagnostic_safety-schiff.pdf
     January 01, 2020 - • Frequent • Important • Overlooked • Matter • Not easy to measure 17 Frequent - #1 Type of Errors … Diagnostic errors 2. Opioid safety across the continuum of care 3. … • Spotty follow-up • Most diagnoses resolve,…or evolve w/errors unnoticed • Elusive to capture with … Research and Quality's activities in patient safety research IOM Report September 2015 Diagnosis Errors … Frequent -#1 Type of Errors Most Common Types of Medical Error Experienced by MA Residents 21% Experienced

273. Diagnostic Safety Issue Briefs | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs.html
     July 01, 2025 - 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 … Pediatric Diagnostic Safety: State of the Science and Future Directions The Contribution of Diagnostic Errors

274. Advancing Patient Safety Through Diagnostic Excellence (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/action-alliance-diagnostic-excellence-webinar.pdf
     June 01, 2025 - c • Organizations can apply tools and strategies to reduce diagnostic errors a. … Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis … Types and origins of diagnostic errors in primary care settings. … • What strategies can healthcare organizations implement to prevent diagnostic errors? … Share With Us What type of diagnostic errors are the top priority in your organization?

275. 124-Cusp-Science-Safety-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
     April 01, 2025 - And as humans, we make errors and can fail. The healthcare system isn’t perfect by any means. … Communication errors are common causes of healthcare errors. … Healthcare is noisy and chaotic, time is often short, and communication errors are common safety risk … As was stated earlier, blaming individual healthcare workers for errors rarely solves safety issues. … Slide 18 Swiss Cheese Model: How Errors Happen SAY: Sometimes defenses fail, and errors line up,

276. Advancing Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advancing-patient-safety.html
     March 01, 2024 - safety findings, investigative approaches, process analyses, and practical tools for preventing medical errors … This compendium describes what federally funded programs have accomplished in understanding medical errors

277. Cognitive Load Theory and Its Impact on Diagnostic Accuracy: Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-cognitive-load-theory.pdf
     May 01, 2024 - Publication No. 24-0010-3-EF. 1 e Introduction to Diagnostic Errors Diagnostic errors, or “the failure … This report suggested that diagnostic errors may contribute to 10 percent of all patient deaths. … Diagnostic errors in hospitalized adults who died or were transferred to intensive care. … The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. … Dual processing and diagnostic errors.

278. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
     March 01, 2002 - , which include errors in the process of ordering or delivering a medication and errors of omission … and pharmacists reduce medication errors. … Relationship between medication errors and adverse drug events. … ASHP Statement on Reporting Medical Errors [ASHP Reports]. … Medication errors observed in 36 health care facilities.

279. Findings | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3.html
     July 01, 2018 - Consumers often have a narrow view of patient safety, seeing safety primarily in terms of medical errors … . 25 , 27 When errors do occur, patients tend to think individual providers cause them, not the systems … However, providers—like consumers and patients—may also view errors as individual deficiencies that are … Patients define patient safety more narrowly in terms of medical errors. … In addition, providers may feel that errors are primarily under an individual's control and therefore

280. Appendix A. Database Search Strategy | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-test-result-communication-apa.html
     July 01, 2024 - Text Search Terms Medline Medline “Diagnostic Tests, Routine” or “Delayed Diagnosis” or “Diagnostic Errors … exp OR ‘diagnostic tests, routine’ OR ‘delayed diagnosis’/exp OR ‘delayed diagnosis’ OR ‘diagnostic errors … ’/exp OR ‘diagnostic errors’ OR ‘false negative reactions’/exp OR ‘false negative reactions’ OR ‘false … *) NEXT/2 (result* OR finding* OR information*))) CINAHL “Diagnostic Tests, Routine” OR “Diagnostic Errors