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401. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
     August 01, 2022 - Slide 7 Say: It is important to understand the distinction between events and errors when … Errors are defined as an act of commission (doing something wrong) or omission (failing to do the right … The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … and errors that are not adverse events.

402. Pediatric Diagnostic Safety Research and Initiatives Across the Care Continuum | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-3.html
     August 01, 2023 - pediatricians surveyed by the AAP Quality Improvement Innovations Network reported making diagnostic errors … at least monthly and errors that harmed patients at least annually. 61 Nearly 90 percent indicated … interest in reducing diagnostic errors, especially for conditions that evolve over months to years (e.g … have begun to address common MDOs through a quality improvement collaborative: Reducing Diagnostic Errors … Further, the reports also generated insights about where in the diagnostic process errors often occur

403. The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Jones_29.pdf
     February 23, 2008 - are viewed as the result of individual failure to one in which errors are viewed as opportunities to … improve the system.2 A voluntary reporting system that emphasizes learning from errors and improving … A commitment at the organizational level to detect and learn from errors. 3. … , and individual RCA of harmful errors) to support a learning culture. … In contrast, errors in nursing were described as “picking on individuals.”

404. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
     January 01, 2024 - Massachusetts Coalition for the Prevention of Medical Errors Lucian L. Leape, M.D. … Massachusetts Coalition for the Prevention of Medical Errors Katherine Howitt, M.A. … Key Words: Patient safety; reporting systems; medical errors: safe practices. Introduction. … Of errors that cause minor harm to the patient, 80% of respondents said that these errors always or … Overall, the respondents identified the scenarios as PSIs and medical errors.

405. Decision Support System Design and Implementation for Outpatient Prescribing: The Safety in Prescribing Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Feldstein.pdf
     January 01, 2004 - medication prescribing has been shown to be an effective method for reducing potential medication errors … Introduction The Institute of Medicine (IOM) report on medical errors identified computerization … One preliminary study5 examined the effect of basic computerized prescribing on medication errors in … as likely to be prevented with CPOE (including 43 percent of the potentially harmful errors). … Outline of SIP education content • Brief introduction to medical errors and SIP project.

406. Creating Safety in the Testing Process in Primary Care Offices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Elder_18.pdf
     February 19, 2008 - Testing represents a common arena for these types of errors. … associated with these events are common; 15 to 54 percent of primary care medical errors reported by … • Just culture: Reporting of issues, problems, events, and errors throughout the organization is … A preliminary taxonomy of medical errors in family practice. … The identification of medical errors by family physicians during outpatient visits.

407. The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-patient-role.pdf
     September 01, 2024 - And they are the ones who must live with the results of diagnostic errors. … Identification and characterization of diagnostic errors have predominantly used a variety of sources … Learning from patients’ experiences related to diagnostic errors is essential for progress in patient … Americans’ Experiences With Medical Errors and Views on Patient Safety. … Types and origins of diagnostic errors in primary care settings.

408. The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception Toward Co-Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/dx-safety-issue-brief-co-design-rev.pdf
     September 01, 2024 - And they are the ones who must live with the results of diagnostic errors. … Identification and characterization of diagnostic errors have predominantly used a variety of sources … Learning from patients’ experiences related to diagnostic errors is essential for progress in patient … Americans’ Experiences With Medical Errors and Views on Patient Safety. … Types and origins of diagnostic errors in primary care settings.

409. Closing Gaps in Research ~ Organizationsand Healthcare Diagnoses (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/goeschel-summit2016.pdf
     June 02, 2025 - diagnostic process GOAL 4 Develop and deploy approaches to identify, learn from, and reduce diagnostic errors … and medical liability system that facilitates improved diagnosis through learning from diagnostic errors … process GOAL 8 Provide dedicated funding for research on the diagnostic process and diagnostic errors

410. 4. Defining Language Need and Categories for Collection | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/iomracereport/reldata4.html
     May 01, 2018 - Evidence on variations in health outcomes, medical errors, and receipt of quality health care as a function … and increased likelihood of clinical errors ( Flores et al., 2005 ; Karliner et al., 2007 ). … (It should be noted that, although research has documented a variety of interpretation errors during … assessments, the clinical significance of such errors has not been well characterized.) … Elderkin-Thompson and colleagues also found interpretation errors in more than 50 percent of videotaped

411. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-references.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 … Learning from patients’ experiences related to diagnostic errors is essential for progress in patient … Views of practicing physicians and the public on medical errors. … Americans’ Experiences With Medical Errors and Views on Patient Safety.

412. Conclusion | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-5.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

413. Making Healthcare Safer III Patient Safety Practices | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/practices.html
     April 01, 2020 - List of Patient Safety Practices Diagnostic Errors ( PDF , 2.3 MB) Clinical Decision Support … ( PDF , 1.8 MB) Opioid Stewardship Medication-Assisted Treatment Patient Identification Errors

414. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/MeasureDx-guide.pdf
     July 01, 2022 - They found 105 confirmed errors representing a variety of diagnoses. … Addressing diagnostic errors: an institutional approach. … Use of e-triggers to identify diagnostic errors in the paediatric ED. … Finding diagnostic errors in children admitted to the PICU. … The global burden of diagnostic errors in primary care.

415. Measure Dx: A Resource To Identify, Analyze, and Learn From Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
     July 01, 2022 - They found 105 confirmed errors representing a variety of diagnoses. … Addressing diagnostic errors: an institutional approach. … Use of e-triggers to identify diagnostic errors in the paediatric ED. … Finding diagnostic errors in children admitted to the PICU. … The global burden of diagnostic errors in primary care.

416. Final Progress Report: Automated Medical Interviewing for Diagnostic Decision Support in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/newman-toker2-report.pdf
     January 01, 2025 - Design Features and Entry Errors. … Diagnostic Errors and Patient Safety – Reply [letter to the editor]. … Diagnostic errors in critical care settings – managing information overload. … Counting deaths due to medical errors. JAMA. 2002;288(19):2404-5. 3. … The importance of cognitive errors in diagnosis and strategies to minimize them.

417. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/distributed-cognition-er-nurses_0.pdf
     August 01, 2022 - Thus, it is no wonder that diagnostic errors occur. … Diagnostic Errors in the Emergency Department: A Sys- tematic Review. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Changes in medi- cal errors after implementation of a handoff program. … The importance of cognitive errors in diagnosis and strategies to minimize them.

418. Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/distributed-cognition-er-nurses.pdf
     August 01, 2022 - Thus, it is no wonder that diagnostic errors occur. … Diagnostic Errors in the Emergency Department: A Sys- tematic Review. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Changes in medi- cal errors after implementation of a handoff program. … The importance of cognitive errors in diagnosis and strategies to minimize them.

419. Appendix A. SIDM Competencies To Improve Diagnosis and Suggested Questions for Debriefing Case Studies | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/nurse-role-dxsafety-apa.html
     September 01, 2022 - continuous learning from analysis and discussion of excellent diagnostic performance, near-misses, and errors … How could your organization share the near-misses, errors, and excellent diagnostic performance from … Disclose diagnostic errors and missed opportunities transparently and in a timely manner to patients, … What problems or gaps do we have at our institution to prevent diagnostic errors like this from occurring

420. K Award Grantee Interview: Christopher Landrigan, M.D., M.P.H. | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/landrigan-transcript.html
     June 01, 2016 - safety—trying to understand what drivers in the health care system are responsible for the epidemic of medical errors … And we found that when we did that, the rates of serious medical errors dropped off very significantly … to accumulate data that sleep deprivation really was a pretty universal problem leading to medical errors