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421. 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?

422. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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.

423. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/maternal-mortality-1.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Introduction Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors … suggests it is imperative to focus on diagnostic safety in obstetrics to prevent and mitigate diagnostic errors

424. 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.

425. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/maternal-mortality-1.html
     September 01, 2021 - The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After … Introduction Previous Page Next Page Table of Contents The Contribution of Diagnostic Errors … suggests it is imperative to focus on diagnostic safety in obstetrics to prevent and mitigate diagnostic errors

426. 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

427. 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

428. Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/16658-Gallagher-report.pdf
     January 01, 2009 - Yet errors are frequently not disclosed to patients. … easily within a blame-free framework for discussing errors. … Disclosing errors to patients: Perspectives of registered nurses. … Health plan members' views about disclosure of medical errors. … Views of practicing physicians and the public on medical errors.

429. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=382
     January 01, 2024 - Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals … Keywords: Adverse Drug Events (ADE), Medication, Medication: Safety, Medical Errors, Patient Safety … Most diagnostic errors in ED appeared to relate to common disease conditions. … Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine. … Keywords: Diagnostic Safety and Quality, Emergency Department, Medical Errors, Risk, Patient Safety

430. 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.

431. 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

432. 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

433. 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.

434. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/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.

435. Create Accurate Reports from Electronic Health Records (EHRs) | Agency for Healthcare Research and Quality
     www.ahrq.gov/evidencenow/tools/ehr-reports.html
     November 01, 2018 - involving care teams in validating data, and the ability of checklists to help detect both inclusion errors … (including patients in the measure that should not have been included) and exclusion errors (patients

436. 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

437. OR-to-ICU Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/dxsafety-care-transitions4.html
     June 01, 2023 - a Call to Action References OR-to-ICU Handoff-Specific Contributors to Diagnostic Errors … found that death after surgery related to communication, system, diagnostic, and judgment error—all errors … significantly higher than death related to technical error. 79 Strategies To Mitigate Diagnostic Errors … These interventions resulted in fewer information omissions and errors, but the statistical quality of … This research could more explicitly explore how the HATRICC bundle could be used to reduce diagnostic errors

438. Getting Ready for Measurement: Overcoming Barriers and Taking Next Steps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-3.html
     June 01, 2020 - Nevertheless, as the burden of diagnostic errors is increasingly recognized and as measurement strategies … to use the data already available to them to begin to detect, understand, and learn from diagnostic errors … While diagnostic errors occur across the spectrum of medical practice, measurement should be strategic … While diagnostic errors occur across the spectrum of medical practice, measurement should be strategic … implementation balance validity and yield (i.e., an estimate of the proportion of cases with diagnostic errors

439. Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/05-sops-teamstepps-webcast-mazur.pdf
     April 30, 2022 - Stepdown Units SOPS Survey -- 1,035 responses over 11 years Key takeaways: Positive: Response to errors … Safety Survey (Communication; 1 unit data only) Communication about error 82 +15 We are informed about errors … that happen in this unit. 80 +15 When errors happen in this unit, we discuss ways to prevent them … Level of explicit culture and teamwork Level of system reliability by design High High Human errors … interact in a predictable manner and can be effectively mitigated Low Low Human errors interact

440. Safe Practices for Better Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
     April 01, 2004 - Not surprisingly, health care errors and consequent adverse events are a leading cause of death and … in the United States,1, 2 even though methods to prevent many of these errors exist. … Use of hand-held electronic prescribing devices to reduce medication errors. 5. … Use of CPOE compared to verbal orders to reduce transcription errors. 8. … Use of simulator-based training to reduce errors. 11.