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21. When It Comes to High-Quality Healthcare, Diagnostic Safety Tops the List | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/news/blog/ahrqviews/diagnostic-safety-tops-the-list.html
    March 01, 2024 - Among those patients, about 18 percent of errors caused temporary harm, permanent harm, or death. … The urgent need to reduce these errors—which include diagnoses that are either inaccurate, delayed, or … Safety Centers of Excellence are working to better characterize, understand, and measure diagnostic errors … and training; health information technology; identification, analysis, and reduction of diagnostic errors … They underscore the imperative to mitigate diagnostic errors and harm.

22. Cinco recomendaciones para recibir una mejor atención médica | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patients-consumers/care-planning/errors/5steps/cincorecsp.html
    September 01, 2014 - https://www.ahrq.gov/patients-consumers/care-planning/errors/5steps/cincorecsp.html  

23. Health Care Simulation to Advance Safety | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/research/findings/factsheets/errors-safety/simulproj15/index.html
    August 01, 2018 - Home Research Research Findings & Reports Fact Sheets Medical Errors … Reports: Patient Safety Evidence-based Practice Center Reports Fact Sheets Medical Errors … https://www.ahrq.gov/research/findings/factsheets/errors-safety/simulproj15/index.html  

24. Final Progress Report: Advancing Patient Safety Innovation in Rheumatology (ASPIRE) (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/2024-02/yazdany-report.pdf
    January 01, 2024 - The proposed Aims were: Aim 1: To analyze the frequency and determinants of errors and adverse events … Among adverse events, medication errors are of particular concern because they are common, costly, and … Despite the frequency of ambulatory patient safety errors and adverse events, most efforts to study … The ASPIRE reach program sought to address this gap by studying ambulatory patient safety errors for … Third, some important patient safety errors are not amenable to EHR-based quality measurement.

25. Diagnostic Safety Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/diagnostic-safety/research/grants-2022.html
    March 01, 2024 - 01 Project Aims: Develop a multidisciplinary diagnostic excellence center to address diagnostic errors … , accelerate its implementation in a large healthcare system, and evaluate its impact on diagnostic errors … Propose, prioritize, and codesign patient-centered solutions to mitigate diagnostic errors. … Carry out a comprehensive program evaluation, including analysis of rates of diagnostic errors and process … and outpatient) to improve patient/family and clinician communication and experience and to reduce errors

26. Tools To Improve Diagnostic Safety | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/diagnostic-safety/tools/index.html
    March 01, 2024 - Healthcare Tools To Improve Diagnostic Safety AHRQ tools to reduce diagnostic errors … Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit aims to assist primary care practice teams … with a systematic approach to reduce diagnostic errors among children in three important areas: elevated … through the measurement, screening, recognition, diagnosis, follow-up, and reduction of diagnostic errors

27. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
    April 27, 2022 - Patient Focus Five studies explored patient reports of diagnostic errors. … Types and origins of diagnostic errors in primary care settings. … Diagnostic error in medicine: analysis of 583 physician-reported errors. … Malpractice claims related to diagnostic errors in the hospital. … Diagnostic errors in medicine: a case of neglect.

28. Diagnostic Safety Centers of Excellence | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/diagnostic-excellence-grants/index.html
    June 01, 2023 - 01 Project Aims: Develop a multidisciplinary diagnostic excellence center to address diagnostic errors … , accelerate its implementation in a large healthcare system, and evaluate its impact on diagnostic errors … Propose, prioritize, and codesign patient-centered solutions to mitigate diagnostic errors. … Carry out a comprehensive program evaluation, including analysis of rates of diagnostic errors and process … and outpatient) to improve patient/family and clinician communication and experience and to reduce errors

29. Diagnostic Errors Are Common in Seriously Ill Hospitalized Adults | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/895.html
    January 01, 2024 - Home News Newsletter AHRQ News Now Diagnostic Errors … Newsroom Blog Newsletter AHRQ News Now Events Diagnostic Errors … Today's Headlines: Diagnostic Errors Are Common in Seriously Ill Hospitalized Adults . … Diagnostic Errors Are Common in Seriously Ill Hospitalized Adults A random sample of patients from … The researchers concluded that three-quarters of these diagnostic errors contributed to temporary or

30. Appendix B: Bringing It To Life - Case Study | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/app-b.html
    September 01, 2020 - English proficiency , which is absolutely necessary to adapt current systems to better identify medical errors … This problem highlights the importance addressing root causes to prevent medical errors among LEP patients … This problem highlights the need to address root causes to prevent medical errors among LEP patients … ensure that staff are comfortable identifying issues, and (2) the need to improve reporting of medical errors … communication and LEP patient safety. 64 , 65 While this case may seem extreme, research shows that errors

31. Toolkit for Engaging Patients To Improve Diagnostic Safety  | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/diagnostic-safety/tools/engaging-patients-improve.html
    July 01, 2022 - Toolkit for Engaging Patients To Improve Diagnostic Safety  Diagnostic errors … Research suggests that 79 percent of diagnostic errors are related to the patient-clinician encounter … and up to 56 percent of these errors are related to miscommunication during the encounter. … , uninterrupted, and in a way that gives clinicians the information they need can reduce diagnostic errors … Organization Toolkit Infographic  (PDF, 743 KB) provides statistics about incidents of diagnostic errors

32. Speaking Plainly: Communicating the Patient’s Role in Health Care Safety (pdf file)
    www.qualitymeasures.ahrq.gov/downloads/pub/advances/vol4/Miranda.pdf
    July 01, 2004 - Others specified particular actions that patients could take to avoid errors, such as maintaining a … refers to “medical errors.” … Agency for Healthcare Research and Quality: 20 tips to help prevent medical errors. … Preventing medical errors: communicating a role for Medicare beneficiaries. … Prescription errors tied to lack of advice: pharmacists skirting law, Mass. study finds.

33. MEASUREMENT OF DIAGNOSTIC ERRORS IS THE FIRST STEP TO IMPROVEMENT (pdf file)
    www.qualitymeasures.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

34. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
    January 01, 2016 - Quality Measures xxVoluntary Reporting Chart Reviews Trigger Tools Automated Measures • 1% of errors … reported • Good for analysis of errors • Not useful as an outcome measure to test interventions … Wrong Patient Errors Leading to Diagnostic Errors: 1) Order tests on wrong-patient 2) Read results of … Wrong Patient Errors Leading to Diagnostic Errors xxVoluntary Reporting Chart Reviews Trigger … Medication Errors in Pediatric Inpatients Charts reviewed of 1120 patients.

35. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
    September 01, 2012 - Patient Safety Terminology Medical errors*: Medical errors happen when something that was planned as … Most errors result from problems created by today’s complex health care system, but errors also happen … If anything, errors related to LEP are bundled as being caused by “communication errors,” which does … We identified three common causes of errors (or potential errors) for LEP and culturally diverse patients … Address Root Causes To Prevent Medical Errors Among LEP Patients Background Medical errors among LEP

36. Brain Based Learning Strategies to Improve TeamSTEPPS® Deployment and Health Care High Reliability | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/teamstepps/events/webinars/jan-2017.html
    January 01, 2017 - Fear of Making Mistakes/Errors Slide 39. Frame Errors Positively Slide 40. … Rather than avoid errors, learners are asked to embrace errors as part of the initial events of learning … (others), Subtle errors (others), Obvious errors (self), subtle errors (self), and error recovery. … All errors need to be represented—slips, errors, mistakes. Dror I. … teams to perform subtle errors and the other team grade them (they circle the errors they will perform

37. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
    September 28, 2016 - Series Foundational Reports 1999 2001 To Err is Human: Building a Safer Health System • Medical errors … action to be completed as intended or the use of a wrong plan to achieve an aim • The majority of errors … • Errors cost $17 billion – $29 billion per year in hospitals in the US However, more recent data … . • Develop a knowledge base for learning about errors' causes and effective error prevention … • Diagnostic errors are the leading type of paid medical malpractice claims • Diagnostic errors can

38. AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors in Emergency Departments | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/news/newsroom/case-studies/cquips0802.html
    October 01, 2014 - Impact Case Studies AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors … Events AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors … June 2008 AHRQ-sponsored research on how clinical pharmacy services can reduce medication-related errors … ASHP aims to prevent medication errors, help people make the best use of medicines, and assist pharmacists … Internet Citation: AHRQ Research Helps Pharmacists in Mentoring Program to Reduce Drug Errors

39. Outpatient Medication Errors Prevalent Among Pediatric Leukemia, Lymphoma Patients | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/news/newsletters/e-newsletter/848.html
    January 01, 2023 - Home News Newsletter AHRQ News Now Outpatient Medication Errors … Today's Headlines: Outpatient Medication Errors Prevalent Among Pediatric Leukemia, Lymphoma Patients … Outpatient Medication Errors Prevalent Among Pediatric Leukemia, Lymphoma Patients An AHRQ-supported … of children with leukemia or lymphoma experienced adverse drug events due to outpatient medication errors … 2023 Page originally created January 2023 Internet Citation: Outpatient Medication Errors

40. The Timeline to Diagnostic Safety SIDM -Research as a Priority (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/graber-summit2016.pdf
    January 01, 2017 - George Bernard Shaw Measuring Diagnostic Errors 15 Human Factors What factors make dx easier … • ER The petri dish for diagnostic errors • Inpatients One in ten diagnoses is probably wrong. 36,000 … Dx errors are COMMON in patients with anemia, asthma, COPD CRICO - Analysis of 4519 claims related … Slide Number 25 Slide Number 26 Diagnostic errors are a significant but underappreciated challenge … BLUNT end���� SHARP end Safer Dx Framework for Measurement & Reduction Measuring Diagnostic Errors