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  1. www.ahrq.gov/research/publications/search.html?page=2
    September 01, 2023 - Diagnostic Safety Issue Brief #15 One of the best ways to collect information about diagnostic errors … 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
  2. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-7.html
    March 01, 2022 - Diagnostic error in medicine—analysis of 583 physician-reported errors . … Accuracy of the Safer Dx Instrument to identify diagnostic errors in primary care . … Patient safety strategies targeted at diagnostic errors—a systematic review . … System-related interventions to reduce diagnostic errors: a narrative review . … Reducing diagnostic errors worldwide through diagnostic management teams .
  3. www.ahrq.gov/hai/cusp/modules/learn/alt-text.html
    April 01, 2013 - Toolkit Demonstrate how to apply the CUSP Toolkit in a clinical environment Review the impact of errors … and patient harm and the underlying causes of errors Show how CUSP supports other quality … Toolkit Demonstrate how to apply the CUSP Toolkit in a clinical environment Review the impact of errors … and patient harm and the underlying causes of errors Slide 3 CUSP Supports Kotter’ … Slide 24 Examples of Defects or Errors That Affect Patient Safety Defect Intervention
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Encinosa.pdf
    January 01, 2003 - One drawback of the IOM report is that its conclusions regarding the cost of medical errors were not … In all our GLM regressions, the robust standard errors were estimated using the Huber/White sandwich … Standard errors are in parentheses. **Significantly different from zero at the 99% level. … Standard errors are in parentheses. **Significantly different from zero at the 99% level. … In fact, we did not consider drug-related errors, diagnostic errors, and errors in choice of therapy
  5. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-6.html
    September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Science References Previous Page   Table of Contents The Contribution of Diagnostic Errors … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. … ‘More than words’ - interpersonal communication, cognitive bias and diagnostic errors. … Reducing diagnostic errors in medicine: what’s the goal?
  6. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety6.html
    September 01, 2022 - The frequency of diagnostic errors in outpatient care: estimations from three large observational studies … Nurses are key in preventing deadly diagnostic errors in cardiovascular diseases. … Diagnosis is a team sport - partnering with allied health professionals to reduce diagnostic errors. … Diagnostic error: safe and effective communication to prevent diagnostic errors . … Communication breakdowns and diagnostic errors: a radiology perspective.
  7. References (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/diagnostic-toolkit/14-diagnostic-safety-toolkit-references.pdf
    November 24, 2020 - Types and origins of diagnostic errors in primary care settings. … Types and origins of diagnostic errors in primary care settings. … Uncharted territory: measuring costs of diagnostic errors outside the medical record. … Contextual errors and failures in individualizing patient care: A multicenter study. … Types and origins of diagnostic errors in primary care settings.
  8. www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalresourcelist.pdf
    January 01, 2019 - By the end of the workshop, participants should: • Be introduced to an understanding of why errors … It makes the case that true transparency will result in improved outcomes, fewer medical errors, more … It highlights bright spots: organizations that use a just culture approach to investigating errors, … Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans To Enhance Safety … The best practices are designed to help alert hospitals and focus their efforts on errors that cause
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_111.pdf
    June 18, 2008 - ” PCA pumps with continuous respiratory monitoring and results achieved in significant programming errors … Numerous factors can lead to opioid-related RD: prescribing errors, PCA pump programming errors, “PCA … Part II: How to prevent errors. ISMP Medication Safety Alert; 2003 July 24. 4. … Part I: How errors occur. ISMP medication safety alert; 2003 July 10. … Design flaw predisposes Abbott Lifecare PCA Plus II pump to dangerous medication errors.
  10. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Graham.pdf
    April 01, 2004 - high organizational priority, and (2) learn from direct care staff and physicians about near misses, errors … This culture must not only address strong accountability, but also must clinicians to report errors … The walkarounds have increased the reporting of actual errors and “near misses,” which has provided … ; it also is important to identify and report potential causes of errors before they occur. … In: Reducing medical errors and improving patient safety.
  11. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety2.html
    September 01, 2022 - recently convened expert panel further stressed the value of a team-based approach to reducing diagnostic errors … 12 Nurses are key members of this team-based approach and well positioned to help reduce diagnostic errors
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
    January 01, 2004 - of ignorance and errors of implementation. … Errors of ignorance are due to inadequate knowledge, whereas errors of implementation occur during application … Cognitive error includes both errors of ignorance and implementation. … A structured teamwork system to reduce clinical errors. In: Spath PL, editor. … Safety errors in emergency medicine. In: Markovchick VJ, Pons PT, editors.
  13. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-cognitive-load-references.html
    May 01, 2024 - Contents Cognitive Load Theory and Its Impact on Diagnostic Accuracy Introduction to Diagnostic Errors … Diagnostic errors in hospitalized adults who died or were transferred to intensive care. … Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working … The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. … Dual processing and diagnostic errors.
  14. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-6.html
    September 01, 2020 - Can we develop checklists for diagnostic error reduction that focus on errors of execution rather than … errors of planning?
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Singer.pdf
    April 01, 2003 - This heightened interest has increased pressure on hospitals to reduce medical errors. … Remember, implementation matters Medication errors received significant attention among consortium … are system errors, and not individual errors. … Residents’ suggestions for reducing errors in teaching hospitals. … In: Enhancing patient safety and reducing errors.
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
    March 01, 2004 - Studies have shown that many physicians are reluctant to participate in programs to report medical errors … collect patient safety information by providing care providers with the means to report events or errors … , care providers hold strong opinions of their own professional responsibilities to address errors. … , even errors related to close calls. … Physician and public opinions on quality of health care and the problem of medical errors.
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Baker_107.pdf
    March 30, 2008 - Walsh and colleagues demonstrated that CPOE does introduce new kinds of errors in pediatric patients … , but they suggested that seriou computer-related errors are rare. … Committee on Identifying and Preventing Medication Errors. Preventing medication errors. … Role of computerized physician order entry systems in facilitating medication errors. … Medication errors related to computerized order entry for children.
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
    December 01, 2017 - These skills are required for changes that will result in safer surgical care. 5 How Do These ErrorsErrors also occur because systems frequently are not designed to catch mistakes before they reach the … Most errors DO NOT belong to individual doctors or nurses. … By accepting that people are not perfect, we are taking the first step toward realizing that medical errors … Science of safety training helps providers and others understand that the majority of errors arise from
  19. www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-presenters-notes.pdf
    January 12, 2022 - Diagnostic errors are a primary reason for medical liability claims. … It is not surprising, therefore, that errors in the process occur. … Appropriate communication can mitigate diagnostic errors. … Communication breakdowns and diagnostic errors: a radiology perspective. … Types of Diagnostic Error Where Do Diagnostic Errors Occur?
  20. www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module1-introduction.pptx
    January 12, 2022 - Diagnostic errors are a primary reason for medical liability claims. … It is not surprising, therefore, that errors in the process occur. … Appropriate communication can mitigate diagnostic errors. … Catch errors that might have been made upstream.   … Communication breakdowns and diagnostic errors: a radiology perspective.

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