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301. Designing Consumer Reporting Systems for Patient Safety Events: Project Overview (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
     July 01, 2011 - since the Institute of Medicine raised national awareness of the prevalence and severity of medical errors … between 44,000 and 98,000 deaths in U.S. hospitals each year are the result of preventable medical errors … Consumer reporting systems may greatly improve our understanding of the nature and causes of medical errors … improved understanding of patient safety and assist in the detection of patterns associated with medical errors

302. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
     January 01, 2017 - Slide 4 Errors Happen Because… SAY: Errors happen because people are fallible. … By accepting that people are not perfect, we are taking the first step toward realizing that medical errors … realize that we can redesign care and delivery processes to improve care and minimize the occurrence of errors … Errors also occur because systems frequently are not designed to catch mistakes before they reach the … Slide 8 The Science of Safety SAY: Science of Safety training helps providers recognize that most errors

303. Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Sirio.pdf
     June 15, 2003 - Data collection Both the MEDMARXSM and NNIS systems track errors and infections through individual … For MEDMARXSM, the methods used to identify potential medication errors vary across hospitals. … • Providing protection and rewards for individuals who report errors. … In: Enhancing patient safety and reducing errors in health care. … Medication errors: experience of the United States Pharmacopeia (USP) MEDMARXSM reporting system.

304. Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
     April 01, 2021 - Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors . … Malpractice claims related to diagnostic errors in the hospital . BMJ Qual Saf. 2017;27(1). … Harried doctors can make diagnostic errors: they need time to think. … The Conversation  2016 Aug 22. https://theconversation.com/harried-doctors-can-make-diagnostic-errors-they-need-time-to-think … Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors .

305. Final Progress Report: Development of an Education Intervention for Triage Interruption Management (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/johnson-ying-report.pdf
     January 01, 2024 - Triage interruptions cause errors. Learning to manage interruptions may improve patient care. … Triage interruptions may lead to errors such as missed symptom identification, incomplete assessment … Background Two decades ago, the IOM reported that healthcare errors and delays were a concern and … Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. … Medication safety initiative in reducing medication errors.

306. AHRQ-Funded Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie.pdf
     June 01, 2023 - 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, … The system identified many more errors than the previous manual process, thereby improving patient … Medication administration errors decreased, and few pump-related errors were made.

307. Final Progress Report: Dissemination of the PPRNet Model for Improving Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/wessell-report.pdf
     January 01, 2024 - The goal of the project was to decrease preventable prescribing and monitoring medication errors in … Preventable medication errors continue to cause harm in the outpatient setting. … Develop a practice-level understanding of the prevalence and consequences of preventable medication errors … execute case management for patients who meet criteria for preventable prescribing and monitoring errors … criteria, or those patients who may be at risk for potential medication prescribing or monitoring errors

308. Final Progress Report: Medication Safety in Primary Care Practice Translating Research Into Practice (MS-TRIP) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/ornstein-report.pdf
     January 01, 2024 - Scope: Medication errors in primary care practice cause morbidity, but work is needed to specify relevant … measures and conduct interventions designed to reduce these errors. … Scope Medication errors in primary care practice are an important cause of morbidity, but the extent … of these errors is largely unknown, and effective interventions for reducing these errors need to … model improved practice performance on several categories of preventable prescribing and monitoring errors

309. | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/publications/search.html?page=4
     November 01, 2020 - instance, checklists have been successful in preventing hospital-acquired infections and preventing errors … The use of checklists has also been recommended as a tool to reduce diagnostic errors. … Diagnostic errors are frequent and often have severe consequences but have received little attention … provide knowledge and recommendations to encourage HCOs to begin to identify and learn from diagnostic errors

310. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
     January 01, 2024 - Potential problems include medication errors, falls, infections, procedural complications, management … errors, diagnostic errors, lack of adequate monitoring, and lack of timely follow-up care. … human factors experts, and systems engineers—who developed an approach for investigating diagnostic errors

311. Digital Healthcare | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-digital.html
     May 01, 2024 - Teams Prioritize and Manage Vulnerable Patients S2: Using EHR-Based Simulations to Reduce Diagnostic Errors … EHR tools, five focus specifically on clinical decision support (CDS) tools to help clinicians reduce errors … data to identify diagnoses at risk for diagnostic error in ambulatory care settings and the EHR use errors … associated with those errors. … In addition, they will provide opportunities for peer learning to reduce interpretive errors and convene

312. Regulation of Health Policy: Patient Safety and the States (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Weinberg.pdf
     March 01, 2004 - Errors may also exhibit characteristics of both omission and commission. … This is especially true of systemic errors. … Reducing medical errors. … Improving patient safety: what States can do about medical errors. … Patient safety and medical errors: a road map for State action.

313. Efficiency Gains with Computerized Provider Order Entry (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
     March 18, 2008 - 0.0001 Discussion The single most studied benefit of CPOE has been the reduction in medication errors … in fewer callbacks for clarification; callbacks interrupt clinical workflow, potentially increase errors … Although much has been written about using CPOE to reduce medication errors,7, 8, 9 there is limited … Role of computerized physician order entry systems in facilitating medication errors. … Leapfrog responds to University of Pennsylvania study on CPOE errors.

314. Final Progress Report: Factors That Enhance Diagnostic Imaging Safety in the Ambulatory Setting (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/lacson-report.pdf
     January 01, 2025 - In order to more accurately elucidate errors related to diagnostic imaging, we also assessed several … In a human factors analysis of various information sources to inform diagnostic process errors, the … SCORE may help reduce errors resulting from diagnostic delays due to unscheduled exam orders. … Other Factors Contributing to Diagnostic Errors (Unscheduled Exams) 17. … Cognitive and system factors contributing to diagnostic errors in radiology. AJR Am J Roentgenol.

315. Final Progress Report: Diagnostic Error in Medicine Conference (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/graber-report.pdf
     January 01, 2025 - stories: • Patient involvement: Susan Sheridan gave an extremely moving presentation on the diagnostic errors … average satisfied or below Total with comments 48 % of non-faculty attendees = 64% 5 Diagnostic Errors … Focus on diagnostic errors is much needed. Great summary of where we are now. … Illuminate diagnostic errors as a major problem in healthcare. … SPECIFIC COMMENT AREAS Diagnostic Error in Medicine 2009 -General Evaluation Summary Diagnostic Errors

316. AHRQ Views: Celebrating the 40th Anniversary of the U.S. Preventive Services Task Force | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/920.html
     July 01, 2024 - Deadline Is Aug. 31 for Submitting Articles to Journal Devoted to Errors in Emergency Care . … Deadline Is Aug. 31 for Submitting Articles to Journal Devoted to Errors in Emergency Care Article submissions … considered for an upcoming special edition of Academic Emergency Medicine dedicated to the science of errors … focus on diagnostic error in emergency care but will explore aspects ranging from the definition of errors … Articles featured this week include: Large language models for preventing medication direction errors

317. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/references.html
     May 01, 2023 - Types and origins of diagnostic errors in primary care settings. … Reducing diagnostic errors in primary care. … Types and origins of diagnostic errors in primary care settings. … Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability … System-related factors contributing to diagnostic errors.

318. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
     December 01, 2017 - Slide 6: How Do These Errors Happen? … Errors also occur because systems frequently are not designed to catch mistakes before they reach the … on the Science of Safety Say: Science of safety training helps providers recognize that most errors … Say: Errors happen because people are fallible. … Science of safety training helps providers and others understand that the majority of errors arise from

319. Teaching Implementation Change Management | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/team/implement/teach-change.html
     February 01, 2024 - Identify errors common to organizational change. … Common Errors Display Slide 75, “Errors Common to Organizational Change.” … This slide lists common errors to avoid. … Errors Common to Organizational Change (5 Minutes) Ask participants what some of the common errors … Compare the errors to those presented in Slide 75.

320. Toolkit to Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-care/safe-transitions.html
     December 01, 2017 - from one ambulatory care facility clinician to another are especially vulnerable to patient safety errors … This toolkit is designed to help staff actively engage patients and their care partners to prevent errors … The toolkit is designed to help staff actively engage patients and their care partners to prevent errors