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441. Patient Safety Research Summaries | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/research-summaries/index.html
     August 01, 2025 - Medication safety refers to the practices and measures implemented to minimize the risk of medication errors … updated July 2025) (PDF, 1 MB): Research shows that improved teamwork reduces the number of medical errors

442. Diagnostic Safety Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
     May 01, 2023 - It thus potentially prevents diagnostic errors by preventing patients from “falling through the cracks … Each guide provides foundational education about diagnostic errors and tangible ideas and suggestions … It highlights bright spots: organizations that use a Just Culture approach to investigating errors, … Harnessing Improvement to Reduce Diagnostic Errors and Delays (Podcast) http://www.ihi.org/resources … Harnessing Improvement to Reduce Diagnostic Errors and Delays (Podcast) 4.

443. Development and Implementation of The University of Texas Close Call Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Martin.pdf
     March 01, 2004 - Texas Close Call Reporting System, an anonymous tool used to collect information about potential errors … and close calls.3–7 Asking health care providers to report errors and close calls is an excellent way … First, given that close calls are believed to have underlying causes similar to those for errors,11, … as opposed to actual errors. … Errors, incidents and accidents in anaesthetic practice.

444. Improving Patient Safety by Engaging Patients and Families (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/ps-research-summary-pfe.pdf
     April 30, 2025 - training providers, as well as other activities designed to report and ultimately prevent medical errors … several projects focused on the role of patients and families in reporting and preventing medical errors … and rated likelihood of medical errors. … Most recommended actions for preventing medical errors were viewed as effective. … medical errors both were linked with a greater likelihood of engaging in preventive action.

445. Envisioning Patient Safety in the Year 2025: Eight Perspectives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Henriksen_104.pdf
     January 01, 2025 - The environment is nonpunitive for errors, which are seen as opportunities for learning, but intolerant … When errors do occur, our pride leads us to respond with surprise (This should never happen here!) … Stress exacerbates all known clinical conditions, increases staff fatigue, and contributes to errors … Also, in the event of medical error, patients and family members will be able to report errors to a … Semi-intelligent software in electromedical devices has reduced errors and enhanced user skill.

446. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-1.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

447. Connecting the Dots: Improving Unit Safety Culture to Stop HAI | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/connecting-dots-slides.html
     December 01, 2017 - shared, learned 1 beliefs and behaviors that reflect an organization’s willingness to learn from errors … We have a just culture that disciplines based on risk taking People who work in teams make fewer errors … (sharp end) Latent errors Just Culture and behavior 17-19 : Conduct: human error, negligence … We are informed about errors that happen in this department. 57% 3. … In this department, we discuss ways to prevent errors from happening again. 59% Slide 37 Learning

448. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
     January 01, 2022 - , MPH*† Objectives: A lack of consensus around definitions and reporting standards for diagnostic errors … D iagnostic errors are common and often represent learning op- portunities to improve the safety and … Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.

449. P-HIP Excel Tool Guidance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/phip-mrabstraction-tool-guidance.pdf
     June 02, 2025 - P-HIP Calculate and save If you get all the way through data entry with no errors, you will see the … P-HIP Export errors If you get an error message similar to the one below, the Excel file had trouble … If the program finds the case and encounters no errors, you will be able to quickly page forward to … Abstraction Tool Navigation and Data Checks Branching Logic Stop -Replace Calculate and save Export errors

450. A Process-centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Akins.pdf
     January 01, 2003 - occur as the result of a chain of errors within a faulty system that is not designed to detect errors … Evaluating medical errors. JONA 1986:16 (4);41–4. 22. Ernst MA, Buchanan A, Cox C. … A judgment of errors. Nurs Times 1991:87(14);26–30. 23. Lilley LL, Guanci R. … CQI case study: reducing medication errors. Jt Comm J Qual Improv 1995;21 (5):232–7. 37. … Incidence and acceptance of errors in medicine.

451. AHRQ Hospital Survey on Patient Safety Culture: Items and Dimensions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
     June 02, 2025 - Our procedures and systems are good at preventing errors from happening. A10. … We are informed about errors that happen in this unit. C5. … In this unit, we discuss ways to prevent errors from happening again. 7.

452. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=0
     December 01, 2024 - Factors, Simulation Publication Date: November 2023 Utility of Predictive Systems in Diagnostic Errors … Publication Date: August 2023 Automated Image Analysis for the Prevention of Radiotherapy Delivery Errors … Topic(s): Nursing Homes, Older Adults Publication Date: July 2023 Identifying and Reducing Errors

453. A Call To Action: Diagnostic Excellence In Rural Healthcare | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-rural-healthcare4.html
     October 01, 2024 - implementing targeted interventions in the short and long term, it is possible to reduce diagnostic errors … payment models, 89 global budgets 90,91 ) do not capture diagnostic accuracy or measure diagnostic errors … accuracy and timeliness has immense potential to enhance patient health outcomes, minimize diagnostic errors

454. Why Are Leaders Essential to Diagnostic Safety? | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-2.html
     June 01, 2021 - These lessons tell us that healthcare leaders need to play an essential role in preventing diagnostic errors … Safer Diagnosis Framework for Measurement and Reduction of Diagnostic Errors 19 (Sociotechnical Work

455. Making Healthcare Safer III: Structured Abstract | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/abstract.html
     March 01, 2020 - issues, healthcare-associated infections, nursing sensitive events, procedural events, and diagnostic errors … to address well-established harms, such as the use of clinical decision support to reduce diagnostic errors

456. Actions Based on Survey Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-culture-survey-brazil-actions.html
     August 01, 2024 - An additional goal is assessment and training to support local efforts to reduce diagnostic errors. … For instance, we are implementing periodic meetings to disseminate lessons learned from diagnostic errors

457. AHRQ's Quality & Patient Safety Programs by Setting: Ambulatory Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/ambulatory/index.html
     June 01, 2025 - implementing a DOAC checklist for ambulatory care pharmacists to reduce clinically important medication errors … Ambulatory Settings is designed to help staff actively engage patients and their care partners to prevent errors

458. A Path to Rural Diagnostic Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-rural-healthcare1.html
     October 01, 2024 - workforce, infrastructure) and geographic isolation, which contribute to an elevated risk of diagnostic errors … 10   Rural healthcare delivery encounters significant obstacles that increase the risk of diagnostic errors

459. Final Progress Report: Improving Safety of Transitions to Skilled Nursing Care Using Video Conferencing (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lipsitz-report.pdf
     January 01, 2024 - Medical errors were identified during 14.7% of ECHO-CT discussions; most were medication related and … We used adjusted generalized logistic regression with robust standard errors clustered on SNFs to estimate … Outcomes: In a separate study to examine the potential impact of ECHO- CT on clinical outcomes, we studied errors … We found that errors were more likely to occur for patients discharged from surgical services or the … Discussion and Conclusions: This study shows that a number of errors may be detected in the post-discharge

460. Improving Patient Safety Using ATHENA-Decision Support System Technology: The Opioid Therapy for Chronic Pain Experience (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Michel_92.pdf
     April 30, 2008 - Introducing information technology can, however, create unforeseen errors.4 For example, a study by … this order entry system increased workload on the health care team and raised the likelihood of new errors … In order to improve patient safety with a decision support system and prevent errors resulting from … Reducing Risk of Prescription Errors To reduce risk for prescription errors, two tools have been provided … Patients may also be harmed by errors in dosing calculations when physicians attempt to switch a patient