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341. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-2.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 … We then extend this information to learning from safety events and diagnostic errors specifically.

342. Appendix D. Organizations and Web Sites | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appd.html
     March 01, 2017 - Patient Safety Maryland Patient Safety Center Massachusetts Coalition for the Prevention of Medical Errors … Council—Calgary, Alberta Patients are Powerful Patients.About.Com Persons United Limiting Sub standards and Errors … in Health Care Persons United Limiting Sub standards and Errors of America Persons United Limiting … Sub standards and Errors of NY Picker Institute Picker Institute Europe Planetree Quality and

343. Final Progress Report: Medications at Transitions and Clinical Handoffs (MATCH) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/noskin-report.pdf
     January 01, 2024 - Purpose (Objectives of the study) It has been estimated that, in the US alone, medication errors cause … 7000 or more deaths per year.1 Nearly 40% of medication errors occur in the prescribing phase,2 and … Pharmacist participation in medical rounds reduces medication errors. … Massachusetts Coalition for the Prevention of Medical Errors (MCPME). … Medication reconciliation: a practical tool to reduce the risk of medication errors.

344. Interplay Between Cognitive Load and Diagnostic Accuracy | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load3.html
     May 01, 2024 - Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors … care setting reduced subjective workload scores, time for task completion, and number of cognitive errors … patient. 21 Multitasking and task switching can also lead to cognitive overload and result in diagnostic errors … of the time. 24 If information is not retrieved with a high degree of accuracy, it can also lead to errors … Instead, the clinician will rely on more intuitive type 1 thinking, which can increase the risk of errors

345. Appendix E. Category Definitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appe.html
     March 01, 2017 - Diagnostic errors, management of test results Definition: Errors in diagnosis, medication, and communication … Reporting such errors is critical to ensuring patient safety and provider accountability.

346. Preface (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Preface.pdf
     February 01, 2005 - Implementation to help the health care system by providing state-of-science information on preventing medical errors … and Alternative Approaches builds on and expands the growing body of evidence for reducing medical errors … iii The bottom line is that improving patient safety and reducing medical errors must continue to

347. Preface (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Preface.pdf
     February 01, 2005 - Implementation to help the health care system by providing state-of-science information on preventing medical errors … and Alternative Approaches builds on and expands the growing body of evidence for reducing medical errors … iii The bottom line is that improving patient safety and reducing medical errors must continue to

348. Preface (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Preface.pdf
     February 01, 2005 - Implementation to help the health care system by providing state-of-science information on preventing medical errors … and Alternative Approaches builds on and expands the growing body of evidence for reducing medical errors … iii The bottom line is that improving patient safety and reducing medical errors must continue to

349. Hospital Survey on Patient Safety Culture Version 2.0: Composites and Items (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdf
     June 02, 2025 - When staff make errors, this unit focuses on learning rather than blaming individuals. A13. … In this unit, there is a lack of support for staff involved in patient safety errors. … We are informed about errors that happen in this unit. C2. … When errors happen in this unit, we discuss ways to prevent them from happening again. C3.

350. Facilitator Guide: Science of Safety Training & Identifying Defects (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
     December 01, 2017 - Slide 5 How Do These Errors Happen? … Errors also occur because systems frequently are not designed to catch mistakes before they reach the … Staff 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

351. Final Progress Report: Developing a Framework to Study and Improve Communication to Enhance Diagnostic Quality in the ED (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/mahajan-manojlovich-report.pdf
     January 01, 2025 - The long-term goal is to reduce diagnostic errors in the ED by improving communication among patients … needed to diagnose ailments, but the role of communication in contributing to or reducing diagnostic errors … Clinicians working in emergency departments (EDs) are particularly vulnerable to making diagnostic errors … Our long-term goal is to reduce diagnostic errors in the ED by improving communication among patients … Diagnostic Errors in the Emergency Department: A Systematic Review [Internet].

352. Pediatric Diagnostic Safety: State of the Science and Future Directions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-pediatric-safety.pdf
     September 01, 2023 - Identification, analysis, and reduction in diagnostic errors. … Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Pediatr. … Overcoming Diagnostic Errors in Medical Practice. J Pediatr. … Diagnostic errors in paediatric cardiac intensive care. Car- diol Young. … Cognitive Errors in Pediatric Emergency Medicine. Pediatr Emerg Care.

353. Vermont Health Clinics Promote AHRQ’s Medication Safety Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202003.html
     June 01, 2020 - involves both health providers and patients is considered the "first line of defense against medication errors … Medication errors are common patient safety incidents in primary care, with rates ranging between 1 and … Medication safety issues include prescribing errors, contraindications, over- and under-prescribing,

354. Tool: Check-Back (or Repeat-Back) | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
     July 01, 2023 - Some misunderstandings lead to serious medical errors, including misdiagnoses. … The message may also be misunderstood because of typing errors or autocorrected spellings that change … What communication errors were avoided?

355. Evaluation of Diagnostic Stewardship Implementation | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship7.html
     August 01, 2024 - diagnostic stewardship interventions improved diagnostic safety outcomes and reduced the risk of diagnostic errors … Other potential diagnostic safety outcomes include diagnostic errors in which testing-related factors … Diagnostic errors can be identified by reviewing a sample of records from the target population (e.g.

356. Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation Challenge Grant (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/jack-report.pdf
     January 01, 2024 - is great discontinuity and fragmentation of care at discharge, resulting in a high rate of medical errors … The products developed can now be tested in a series of RCTs, measuring the rates of medical errors … More people die in a year from medical errors than from car accidents (43,458), breast cancer (42,297 … errors and designs a system that will minimize their impact. … What is the Best Hospital Discharge to Prevent Medical Errors: A guideline.

357. Unique Challenges in Approaching Diagnostic Safety in Older Adults | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults2.html
     September 01, 2024 - Patient, clinician, and structural factors contributing to diagnostic errors in older adults   Patient … reports in the medical literature that were published in the last 10 years and describe diagnostic errors … Examples of case reports with diagnostic errors of common health concerns in older adults Authors Title … inaccurate medication lists are common in these patients’ EHRs, thereby contributing to diagnostic errors … This scenario places older adults with MCCs at higher risk for diagnostic errors.

358. Transforming Hospitals: Designing for Safety and Quality (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/transform.pdf
     January 01, 2020 - a Safer Health System, exposed the tremendous costs, both in human and financial terms, of medical errors … indicate that between 44,000 and 98,000 people die each year in the United States as a result of medical errors … The national cost to the economy of these errors is between $17 billion and $29 billion. … change their cultures and care processes to produce safer health care environments with fewer medical errors … .13 3 Patient rooms that can be adapted for the acuity of a patient can also reduce errors.

359. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
     January 01, 2010 - While the IOM made recommendations to Congress for investigating medical errors and improving patient … The IOM noted that many of the errors in health care result from a culture and system that is fragmented … Later in 2000, under AHRQ leadership, that task force held a National Summit on Medical Errors and … these grants was to: • Explore different ways of reporting, analyzing, and using data on medical errors … While the Institute of Medicine made recommendations to Congress for investigating medical errors

360. Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
     May 19, 2003 - Burns Abstract Heparin administration errors can have severe consequences for patients. … administration process through the use of a computerized protocol at a large Midwestern hospital, errors … still occurred—2.01 errors per 1,000 doses charged. … This is likely to lead to errors, either in the conversion of one unit of measurement to the other … It is likely that inexperience of this kind would make errors more likely to occur.