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261. 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.

262. Final Progress Report: Diagnostic Error in Medicine Annual Conference (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/trowbridge-report.pdf
     January 01, 2025 - In the inpatient population, diagnostic errors represent the second largest cause of adverse events, … Types and origins of diagnostic errors in primary care settings. … Counting deaths due to medical errors JAMA. 2002;288(19):2405. 8. … System-related interventions to reduce diagnostic errors: a narrative review. … Diagnostic error in medicine: analysis of 583 physician-reported errors.

263. Making Healthcare Safer IV | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs4/index.html
     April 01, 2025 - I, II, and III have shown a positive impact of patient safety practices on the reduction of medical errors … evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors … evident during the pandemic, the harms and patient safety practices to reduce the risk for medical errors … Adults (Feb. 1, 2024) Report Protocol Computerized Clinical Decision Support To Prevent Medication Errors

264. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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.

265. 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.

266. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
     April 27, 2022 - Patient Focus Five studies explored patient reports of diagnostic errors. … Types and origins of diagnostic errors in primary care settings. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Malpractice claims related to diagnostic errors in the hospital. … Diagnostic errors in medicine: a case of neglect.

267. Eliciting Patients’ Diagnostic Experiences Using Rigorous Methods | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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,”

268. 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,”

269. 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.

270. 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
     September 30, 2024 - 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.

271. 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

272. Final Progress Report: Minimizing Error, Maximizing Outcome (MEMO): The Physician Worklife Study II (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/linzer-schwartz-report.pdf
     January 01, 2024 - Charts were audited for care quality and errors. … Lack of quality emphasis is linked to past errors. … of errors). … Medical errors were covered in the fifth and sixth sections. … errors.

273. Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-psychological-safety.pdf
     September 01, 2023 - Publication No. 23-0040-6-EF. 1 e Learning From Diagnostic Errors Diagnostic errors are both frequent … The goal of reporting and analyzing errors should be to promote insight, create solutions, and enable … Malpractice claims related to diagnostic errors in the hospital. … Voluntary electronic reporting of medical errors and adverse events. … Reflection on medical errors: a thematic analysis.

274. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - Barriers to reporting near-miss errors include the additional workload burden imposed by a reporting … Factors that influence how students and residents learn from medical errors. … How surgeons disclose medical errors to patients: a study using standardized patients. … Lost opportunities: how physicians communicate about medical errors. … A preliminary taxonomy of medical errors in family practice.

275. 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
     December 01, 2024 - 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

276. 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.

277. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
     August 01, 2022 - Thus, it is no wonder that diagnostic errors occur. … of distributed cognition would be a major advance in the quest to limit harm associated with these errors

278. New Patient Safety Network Cases Offer Commentaries on Avoiding Severe Medical Errors | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/avoiding-severe-medical-errors.html
     January 01, 2022 - New Patient Safety Network Cases Offer Commentaries on Avoiding Severe Medical Errors Two … the Web case studies from AHRQ’s Patient Safety Network (PSNet) include expert analyses of medical errors

279. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ehr-impact6.html
     July 01, 2024 - Detailed documentation enhances patient safety by reducing the risk of diagnostic errors and facilitating … However, specific knowledge about diagnostic errors within EHR documentation is limited, indicating a

280. Appendix B: Bringing It To Life - Case Study | Agency for Healthcare Research and Quality
     www.ahrq.gov/health-literacy/professional-training/lepguide/app-b.html
     September 01, 2020 - English proficiency , which is absolutely necessary to adapt current systems to better identify medical errors … This problem highlights the importance addressing root causes to prevent medical errors among LEP patients … This problem highlights the need to address root causes to prevent medical errors among LEP patients … ensure that staff are comfortable identifying issues, and (2) the need to improve reporting of medical errors … effective communication with LEP patients, we can develop a culture of patient safety that will prevent errors