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41. S2: Using EHR-Based Simulations to Reduce Diagnostic Errors in Ambulatory Care Settings | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/reports/2024-annual-report/spotlight-s2-gold-ratwani.html
    May 01, 2024 - Investments in Primary Care Research for 2021 and 2022 S2: Using EHR-Based Simulations to Reduce Diagnostic Errors … Use of electronic health records (EHRs) can contribute to diagnostic errors, often because of system … powerful tool that can be used to both systematically study the ways EHRs contribute to diagnostic errors … data to identify diagnoses at risk for diagnostic error in ambulatory care settings and the EHR use errors … associated with those errors.

42. Final Progress Report: RCT to Reduce Prescribing Errors in Hypertension (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/soumerai-report.pdf
    January 01, 2024 - Final Progress Report: RCT to Reduce Prescribing Errors in Hypertension Principal Investigator: Soumerai … AHRQ GRANT FINAL PROGRESS REPORT RCT TO REDUCE PRESCRIBING ERRORS IN HYPERTENSION Principal Investigator … compare two educational interventions, group versus individual academic detailing, to reduce prescribing errors … Key Words: Hypertension, medication errors, patient safety PURPOSE The main objective of the study

43. AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors in E.D. Patients | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/201509.html
    January 01, 2018 - AHRQ Research Inspires Efforts at Banner Desert To Reduce Drug Errors in E.D. … May 2015 AHRQ-sponsored research on how clinical pharmacy services can reduce medication-related errors … The Institute of Medicine has identified medication errors as the most common type of error in health

44. ED-to-Hospital Transitions | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions2.html
    June 01, 2023 - ED-Specific Contributors to Diagnostic Challenges and to Diagnostic Errors and Uncertainty EDs are … in the ED are generally considered multifactorial. 19 In addition to being common, diagnostic errors … Second, and relatedly, early diagnostic errors can propagate other types of medical errors such as admission … . 12 , 15 ED-to-Ward Handoff-Specific Contributors to Diagnostic Errors and Uncertainty Because of … In conclusion, the ED-to-hospital transition is a high-risk time for diagnostic errors.

45. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-1.html
    June 01, 2020 - Measurement: Overcoming Barriers and Taking Next Steps Conclusion References Diagnostic errors … resulting in substantial preventable morbidity and mortality and excess healthcare costs. 1 Diagnostic errors … organizations (HCOs) to “monitor the diagnostic process and identify, learn from, and reduce diagnostic errors … endorses hundreds of measures), 4,5 none is being used routinely to assess and address diagnostic errors … safety, and the development of diagnostic safety measures remains in its infancy. 6 However, diagnostic errors

46. Final Progress Report: Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS) (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
    January 01, 2025 - Most studies on patient safety focus on errors of commission rather than errors of omission. … Errors of omission are difficult to identify and measure. … ECOS is a survey tool designed to measure errors of omission in primary care. … System-related factors contributing to diagnostic errors. … Reducing errors of omission in chronic disease management.

47. Appendix, Sample Letter to Discipline-Specific Leaders on Meeting Regarding Training and Implementation Strategy for Medication Reconciliation | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/patient-safety/settings/hospital/match/appendix/app-8.html
    July 01, 2022 - [Insert Organization Logo Here] [Insert date] To [Insert Stakeholder] , Medication errors … are one of the highest single-volume sources of medical errors. … Unfortunately, many of these medication errors are associated with direct harm to patients.

48. Appendix, Sample Letter to Discipline-Specific Leaders on Meeting Regarding Training and Implementation Strategy for Medication Reconciliation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-8.html
    July 01, 2022 - [Insert Organization Logo Here] [Insert date] To [Insert Stakeholder] , Medication errors … are one of the highest single-volume sources of medical errors. … Unfortunately, many of these medication errors are associated with direct harm to patients.

49. Final Progress Report: Putting a Face on Hospital Medical Errors: Communication (pdf file)
    www.ahrq.gov/sites/default/files/2024-11/stewart-report.pdf
    January 01, 2024 - Final Progress Report: Putting a Face on Hospital Medical Errors: Communication FINAL REPORT Putting … a Face on Hospital Medical Errors: Communication Project funded by: Agency for Healthcare Research … Patient’s and Physicians Attitude Regarding the Disclosure of Medical Errors. … Health Plan members’ Views about Disclosure of Medical Errors. … Communicating with Patients about Medical Errors.

50. Making Healthcare Safer Practices: 11. Patient Identification Errors in the Operating Room (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/patient-id-errors-1.pdf
    March 01, 2020 - Patient Identification Errors in the Operating Room Patient Identification Errors in the Operating … errors. … Patient Identification Errors. 2016. … One evidence review examined errors in intensive care units. … Patient Identification Errors in the Operating Room PRISMA Diagram Appendix B.

51. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
    July 01, 2003 - The identification and characterization of medication errors occurring in the Medical Errors Prior … Definitions of medication errors differ, depending on one’s perspective. … Even using IT to evaluate medication errors requires careful planning. … Relationship between medication errors and adverse drug events. … Reducing the frequency of errors in medicine using information technology.

52. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-dx-stewardship2.html
    August 01, 2024 - Implementation Opportunities and Challenges Ahead Conclusion References Diagnostic errors … synthesis, including in the use of diagnostic testing. 1,2 In several comprehensive analyses of diagnostic errors … followup) are among the most prominent contributing factors. 1 , 3-5 In contrast to clinical reasoning errors … clinical laboratory into a broader strategy to advance accurate and timely diagnoses and reduce diagnostic errors

53. Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/West.pdf
    September 01, 2005 - errors. … and diagnostic testing errors. … These errors represent nearly 60 percent of all medical errors reported to ASIPS in which clinical harm … • Diagnostic testing errors (with a focus on lab tests): More than 50 percent of all medical errors … and identify errors immediately when they occur.

54. AHRQ Papers on Diagnostic Safety Topics | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/dxsafety-issuebriefs.html
    July 01, 2025 - AHRQ Papers on Diagnostic Safety Topics Diagnostic errors occur in all settings of care, contribute … 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 … Improving Education—A Key to Better Diagnostic Outcomes ( PDF , 2 MB) The Contribution of Diagnostic Errors … Journal Articles The PRIDx framework to engage payers in reducing diagnostic errors in health care  (

55. Final Progress Report: MOVES: Patient-Based Strategy To Reduce Errors in Diabetes Care (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/oconnor-report.pdf
    January 01, 2024 - Results: Among patients with errors at baseline, 59.3% of errors were resolved by the end of the study … Interventions failed to reduce errors of commission (inappropriate use of medications; p>0.05) or errors … No pre-intervention errors. … No pre-intervention errors. … No pre-intervention errors.

56. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
    www.ahrq.gov/downloads/pub/advances/vol2/Schiff.pdf
    January 01, 2005 - Diagnosis errors are challenging to detect and dissect. … malpractice claims revealed that diagnosis errors far outnumber medication errors as a cause of claims … Diagnosing Diagnosis Errors 257 T ab le 1 . … Unsuspected additional errors also emerge. … Diagnosis* Errors A B C D E F G Diagnosing Diagnosis Errors 265 Clinician assessment

57. MEASUREMENT OF DIAGNOSTIC ERRORS IS THE FIRST STEP TO IMPROVEMENT (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/singh-summit2016.pdf
    September 01, 2016 - MEASUREMENT OF DIAGNOSTIC ERRORS IS THE FIRST STEP TO IMPROVEMENT MEASUREMENT OF DIAGNOSTIC ERRORS … www.houston.hsrd.research.va.gov/bios/singh.asp https://twitter.com/hardeepsinghmd ��measurement of Diagnostic Errors

58. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schiff.pdf
    January 01, 2005 - Diagnosis errors are challenging to detect and dissect. … malpractice claims revealed that diagnosis errors far outnumber medication errors as a cause of claims … Diagnosing Diagnosis Errors 257 T ab le 1 . … Unsuspected additional errors also emerge. … Diagnosis* Errors A B C D E F G Diagnosing Diagnosis Errors 265 Clinician assessment

59. Using Data Mining to Predict Errors in Chronic Disease Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-McCabe_39.pdf
    March 28, 2008 - Using Data Mining to Predict Errors in Chronic Disease Care Using Data Mining to Predict Errors in … Errors of Omission Feedback strategies committed more errors of omission than feedforward strategies … All models committed fewer errors in the low A1c cells (feedforward strategies committed no errors). … Precision is the percentage of the actual errors among all the encounters that were classified as errors … and overpredicting errors.

60. Past Research on Patient Perceptions of Safety and Diagnostic Mishaps | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-3.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 … Perceptions of Safety and Medical Errors from Patients’ Perspectives Four past findings have relevance … They were, in fact, directly related to the hole in my new valve….No one spoke to me about the errors … Types and prevalence of patient/family-reported diagnostic errors Type of Diagnostic Error