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421. Reinforcing the Value and Roles of Nurses in Diagnostic Safety - Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/nurse-role-dxsafety.pdf
     September 02, 2022 - AHRQ Publication No. 22-0026-4-EF. 1 e Introduction Diagnostic errors are common and costly, … 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.

422. Learn About CUSP | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/learn/sl-cusp.html
     December 01, 2012 - Examples of Defects or Errors That Affect Patient Safety Slide 25. … Review the impact of errors and patient harm and the underlying causes of errors. … Identify Defects Through Sensemaking Introduce CUSP and Sensemaking tools to identify defects and errors … Examples of Defects or Errors That Affect Patient Safety   Defect Intervention Unstable … Communication is cited as a root cause of most errors.

423. Chapter 1. Environmental Scan | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program1.html
     April 01, 2018 - and elimination or mitigation of patient injury caused by health care errors. … safety involves the establishment of operational systems and processes that minimize the likelihood of errors … and maximize the likelihood of intercepting errors when they occur. … These events include "errors," "deviations," and "accidents.” … Patient safety efforts aim to reduce errors of commission or omission.

424. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol1-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 … Types and origins of diagnostic errors in primary care settings. … Americans’ Experiences With Medical Errors and Views on Patient Safety.

425. Improving Safety Using Teamwork and Patient Safety Norms (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
     June 30, 2025 - observed team behaviors • > 25% increase in speaking up • Improved resuscitation with 39% less med errors … improvement in safety, organizational learning, teamwork (intra- & inter-), staffing, response to errors … speak up: • Hierarchy • Retribution • Excessive courtesy When team doesn’t speak up: • Diagnostic errors … • Medication errors • Delays in treatment Advocacy: Not who is right, what is right (for the patient … • Anything that you do not want to happen again Errors Provide Useful Information • We can learn

426. Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
     January 01, 2004 - A study of the ethical duty of physicians to disclose errors. … Medication errors: the nursing experience. Albany, NY: Delmar Publishers, Inc.; 1994. 10. … Patients’ and physicians’ attitudes regarding the disclosure of medical errors. … Disclosing medical errors: practical, ethical and legal considerations. … Health plan members’ views about disclosure of medical errors.

427. Introduce CUSP
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/learn/learncusp.pptx
     April 01, 2011 - Introduce CUSP 1 Learning Objectives Review the impact of errors and patient harm and the underlying … causes of errors Show how CUSP supports other quality and safety tools Describe Comprehensive Unit-based … Identify Defects Through Sensemaking Introduce CUSP and Sensemaking tools to identify defects and errors … combines the CUSP steps Identify Defects and Learn from Defects 23 23 Examples of Defects or Errors … supports a broad range of quality and safety models Communication is cited as a root cause of most errors

428. Introduction | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults1.html
     September 01, 2024 - Older adults are at higher risk for diagnostic errors than younger adult populations for multiple reasons … few efforts exist to summarize existing literature focused on understanding and addressing diagnostic errors

429. Communication and Optimal Resolution (CANDOR) Toolkit Module 3: Preparing for Implementation: Change Readiness and Gap Analysis
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
     August 25, 2015 - McGraw Hill Medical, 2012. 8 It is important to understand the distinction between events and errors … 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. 8 Develop a Measurement Strategy5 WHAT to measure Process,

430. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/match/references.html
     July 01, 2022 - Medications At Transitions and Clinical Handoffs (MATCH) Study: an analysis of medication reconciliation errors … Preventing Medication Errors: Quality Chasm Series , 2006. … http://iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx .

431. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/match/references.html
     July 01, 2022 - Medications At Transitions and Clinical Handoffs (MATCH) Study: an analysis of medication reconciliation errors … Preventing Medication Errors: Quality Chasm Series , 2006. … http://iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx .

432. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-7.html
     September 01, 2020 - Checklists to reduce diagnostic errors. Acad Med. 2011;86:307-313. … Patient safety strategies targeted at diagnostic errors: a systematic review. … Checklists to prevent diagnostic errors: a pilot randomized controlled trial.

433. Final Progress Report: Risk Assessment of the Testing Processes of Access Community Health Network (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/eder-report.pdf
     January 01, 2024 - During the past 10 years, investigators have described the errors that occur in the testing process … in primary care practices and the reasons these errors occur. … Even if errors in the testing process occur infrequently, there is still great opportunity for harm … The lack of published studies makes it impossible to estimate the prevalence of errors within the … The lack of standardization in testing processes results in inefficiencies and errors.

434. Final Progress Report: Evaluation of Risk by Active Surveillance in the Emergency Department (ERASED) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/hall1-report.pdf
     January 01, 2024 - Key Words: patient safety, emergency medicine, errors, adverse events, harm Principal Investigator … Aim 2 – Compare errors and adverse events through active surveillance with those identified through … Current knowledge about the number and types of errors and adverse events occurring within emergency … Only a small number of studies have evaluated the epidemiology of errors and adverse events within the … Active surveillance aids in the detection and description of a wide range of errors as they occur.

435. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
     March 27, 2008 - NYPORTS provides useful information about systems errors and effectiveness of prevention strategies. … These errors occurred in a wide variety of locations (Table 3). Table 3. … Some intraoperative errors were reported under this code (e.g., wrong segment of colon connected to … Of the 20 Code 912 errors in bedside procedures, eight were chest-tube cases (two wrong patient, six … Discussion According to the National Quality Forum (NQF), “never events” are “errors in medical care

436. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/corbett.html
     August 01, 2017 - Introduction Health systems expend considerable resources to reduce medication errors in hospital settings … Increasingly, inpatient medication risk management efforts focus on preventing errors by improving systems … the potential for patient harm and increased medical liability due to medication discrepancies and errors … When errors that result in harm occur, full disclosure is the best practice. … Patients’ and physicians’ attitudes regarding the disclosure of medical errors.

437. Background and Information for Translators of the AHRQ Hospital Survey on Pateint Safety Culture Version 2.0 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospital/sops-hsops-2-translation-guidelines.pdf
     August 01, 2023 - When staff make errors, this unit focuses on learning rather than blaming individuals. … In this unit, there is a lack of support for staff involved in patient safety errors. … (negatively worded) • More about this item: When staff are involved with patient safety errors, there … 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.

438. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
     August 01, 2022 - Ask: How would you describe the organization's culture relative to blame or responsibility for errors … A Just Culture supports disclosure and learning from errors and encourages viewing every event as an … Human errors are abundant and inevitably repeated when system processes are not corrected or adjusted … Only then can we learn why errors were truly made, and how we can implement policy, process, and improvement … mechanisms to prevent the same errors from happening again.

439. Advances in Patient Safety: New Directions and Alternative Approaches | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances-new-directions/index.html
     July 01, 2022 - The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis … Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (   PDF , 109 KB ) … Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS … Using Data Mining to Predict Errors in Chronic Disease Care (   PDF , 660 KB ) Ryan M. … Using Home Visits to Understand Medication Errors in Children (   PDF , 622 KB ) Kathleen E.

440. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
     April 09, 2004 - The pervasive focus on medical errors in the U.S. health care system gained momentum in 1991, when a … Reporting Program [MER]; MEDMARxSM, a national database for medication errors). … Federal Actions to reduce medical errors and their impact; 2000 Feb. 5. Flowers L, Riley T. … State-based mandatory reporting of medical errors. … The Institute of Medicine report on medical errors: could it do harm?